NOTE: You can either print this form and include it with your payment or submit it online, leaving the signature area blank, and be sure to print and include the PARENT PERMISSION FORM, the CPR-FIRST AIDS-MEDS FORM and the CAMPER'S PICK UP FORM, all of which are accessed from Camp Forms on the left menu, with your payment

A physician's signature is not required on this form, however, we strongly encourage the camper to have a yearly physical check-up by the family doctor. One annual physical check-up is covered by OHIP.

Egalacres Farm Camp
RR#2
Beeton, Ontario
L0G 1A0

Phone: 905-729-4385 or 905-729-2627
Fax: (905) 729-2628

Click Here to E-mail


CAMPER HEALTH HISTORY

DISCLAIMER

While every precaution has been taken in the preparation of this material, the Healthcare Committee assumes no responsibility for errors and omissions.

The material is intended only as a guide and may not address all needs or situations. The responsibility for assessing and determining actions rests solely with the individual and/or Camp.

EGALACRES OWNERS AND STAFF WILL NOT BE RESPONSIBLE FOR LOSS OF PROPERTY OR ANY INJURIES OR ACCIDENTS OCCURRING ON OUR PREMISES.



CAMPER INFORMATION


Camper's Name:

Date of Birth:

Sex:

Age:

Address:

City/Town:

Postal Code:

E-Mail:

Home Phone:



Health Card Number:

Version Code:

Other Health Insurance:

Week(s) you would like to attend Camp:



Parent/Guardian:

Address (if different from above):

Phone(s):


Emergency Contact:

Relationship:

Address:

Phone(s):



PHYSICIAN INFORMATION

Family Physician:

Phone:

Date of last examination (dd/mm/yy):


Specialist Name/Type:

Phone:



HEALTH HISTORY

ALLERGIES:
Drugs:

Insect Stings or Bites:

Seasonal Allergies (i.e. Hay Fever):

Other Reactions:

Carries Ana-Kit:

Carries Epi-Pen:



RECENT ILLNESS, OPERATIONS or INJURIES

Is camper under any form of treatment/medication for any illness, condition or injury? If yes please explain:?

Will this condition limit or affect his or her participation in activities? If yes please explain:?


Advise the child’s level in swimming:

- do they require a life jacket in the shallow and/or deep end?

- do they require water wings in the shallow and/or deep end?


Name the siblings of the camper that are also attending camp:


Advise if the camper has attended Egalacres Farm Camp before:


Advise if your child/children wishes to be in the same group as any other child/children attending camp:



OTHER HEALTH ISSUES : (Please List All Other Health Issues)

Explanation and treatment of above issues and concerns:


Does the camper wear glasses or contact lenses?



FOR FEMALE PARTICIPANTS


Has she menstruated?

If No is she informed on this issue?



MEDICATIONS BEING SENT
(If you need more space please write on the back)

Medication Name, Dosage, Administration, Times, Reason

1:
2:
3:
4:
5:
6:
All medications must be in original containers and clearly labeled.

Does the camper take any other medications that will not be sent to camp? If yes please explain:


Specific Activities to be Encouraged or limited:





AUTHORIZATION

To the best of my knowledge, this camper does not have a communicable disease, has not been in contact with anyone who has a communicable disease within 3 weeks of the camp session from start date, and is physically able to participate in all activities except as indicated. All medical problems, or conditions requiring ongoing medical supervision or care, have been fully noted. I give permission for this health information to be shared with the appropriate camp staff and outside medical personnel as necessary. If the parent cannot be reached, permission is hereby, given to the camp staff to take whatever steps it deems necessary to ensure the safety and health of the camper. This also allows permission for the camp to contact the camper’s family physician/specialist. (Please inform your physician/specialist that you have given this authorization). I hereby, certify that all information completed in this form is accurate and up to date. I will contact the camp, in writing, if any changes occur in camper’s health status.


Parent/Guardian Name: (Please print)_______________________________________________


Signature: _________________________________________________


Date: _____________________