To be completed by parent or guardian

Name of child: ------ Date of Birth: 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 Jan Feb Mar Apr May Jun n> Jul Aug Sep Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Gender: Male Female ------ Age: 5 6 7 8 9 10 11 12 13 14 15 ------ Medicare Card No.

Name of parent or Guardian:
E-mail:
--- Phone: (Office) --- (Home) (Cell.)

Address:
--------- Street & Number ----------------------- City -------- Prov. --- Postal Code

If not available in an emergency please notify:

Name: --- Phone:

Address:
------- Street & Number ------------------------ City ------- Prov. ---- Postal Code

PRESENT PROBLEMS: TO BE FILLED IN BY PARENT OR GUARDIAN (yes or no)

ALLERGIES:

Medication Presently Receiving:

Any physical handicap – describe:

Any restricted activities – describe:

SUGGESTIONS AND FURTHER EXPLANATION FROM PARENT/GUARDIAN:

IMPORTANT: Please notify the camp if this camper has been exposed to any communicable disease during the three week period prior to camp attendance.

PARENTS/GUARDIAN AUTHORIZATION:
This health history is correct as far as I know, and the person herein described has permission to engage in all prescribed camp activities, except as noted above. In the event I cannot be reached in an EMERGENCY, I hereby give permission to the physician selected by the Camp Director to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child as named above.

I agree to the above and certify that this form is accurate to the best of my knowledge: ------
Name:

N.B. ANY REQUIRED MEDICATIONS PRECRIBED BY A PHYSICIAN FOR THE CAMP PERIOD MUST BE HANDED TO THE CAMP DIRECTOR ON ARRIVAL AT CAMP.

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