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CAMP MISAWANNEE STAFF MEDICAL WAIVER

Staff First Name

Staff Last Name

Parent First Name

Parent Last Name

Parent Phone Number

Staff Date of Birth

Staff Care Card Number

Parents/Family Email

Street Address

Street Address Line 2

City

Province

Postal Code

Family Doctor

Family Doctor Phone

Do you suffer from a medical condition, illness, or injury?

No

Yes

Have you been hospitalized in the last 12 months?

No

Yes

If you answered yes to any question, please elaborate

Do you have allergies?

Yes

No

If yes, what are they allergic to?

Gluten (Celiac)

Gluten (Intolerant)

Nuts (any and all kinds)

Seafood/Shellfish

Dairy

Eggs

Please list any allergies not listed above:

Do you require medication?

Yes

No

What medications do you take? List name, dosage and frequency.

Medical Release: I, the parent or legal guardian of the camper mentioned above, hereby delegate the authority to the leaders of camp to arrange whatever medical treatment they deem necessary during my daughter's stay at camp. I hereby declare that the camp staff shall not be reponsible for any injury or loss suffered by my daughter except insofar as any such loss is solely attributable to the negligence of the staff of camp acting witin the course of their duties. I further consent to the transportation of my daughter from the camp to the nearest hospital or clinic.

Staff Signature (if over 18)

Dated:

Thanks for submitting your Medical Waiver form.

Vancouver, B.C. | crestwellstudycentre.com

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