Medical Waiver 2023 | Camp Misawannee

CAMP MISAWANNEE MEDICAL WAIVER FORM

IMPORTANT: Health form must be submitted to our camp office upon registration. Updates can be submitted later by email. Please ensure it is filled out completely & accurately. Campers cannot attend camp without a current health form on file prior to camp.

CAMPER INFORMATION

Camper First Name

Camper Last Name

Camper Age

Grade in September 2023

Camper Date of Birth

Home Phone Number

Street Address

City

Postal Code

EMERGENCY CONTACTS

Parent Name

Parent Cell Number

Parent Email

Emergency Contact

Emergency Contact Cell Number

Relation to Camper

Other Emergency Contact

Phone Number

Relation to Camper

MEDICAL INFORMATION

Camper Personal Health Number (PHN)

Expiry Date mm/yr

Family Doctor

Family Doctor Phone

Family Dentist

Family Dentist Phone

ALLERGIES

Does your child have allergies?

Yes

List any other allergies not shown:

EPI-PEN

Does your child require an EpiPen?

Yes

If yes, please provide details about your camper's anaphylaxis.

***If your child is required to carry their EpiPen (.e. bee/wasp allergy), please provide two non-expired EpiPens; one for your child to carry with them and one to keep in the Health Centre.***

DIETARY RESTRICTIONS

Check all dietary restrictions

Vegetarian

Vegan

Lactose Intolerant

Gluten Free

Peanut Allergies

Tree Nut Allergies

Fish Allergies

Shellfish Allergies

Dairy Allergies

Egg Allergies

Soy Allergies

Gluten Intolerance

Please list any other dietary restrictions not listed above:

ASTHMA/INHALER

What are the triggers for these attacks?

If your child will be carrying their puffer with them, please bring an extra non-expired puffer to be left in the Health Centre. If you child has used their puffer in the last year, they are required to have a puffer at camp.

MEDICATIONS AT CAMP:

Will your child be taking any medications while at camp (prescription or homeopathic)?

If yes, list medications, dosage, schedule, route, and reason for medication:

ALL PRESCRIPTION AND OVER-THE-COUNTER MEDICATIONS MUST BE LEFT WITH THE HEALTH CARE STAFF WHILE AT CAMP. Prescription medication brought to camp must be in its original packaging and must be labeled with the doctor's name, child's name, dosage, schedule, route and date. If any over-the-counter medications are sent to camp with your child, they must be in the original package and left with the Health Care Staff.***

MEDICATIONS AT HOME/TREATMENTS:

Does your child regularly take any medications that will NOT be taken at camp? Will your child require any treatments while at camp?

If yes, please elaborate:

OVER-THE-COUNTER MEDICINE AT CAMP

May the following over-the-counter medications be given to your child while at camp, if deemed necessary by the nurse or first aid attendant?

Is there anything the camp needs to be aware of when giving any of the approved over-the-counter medications to your child?

HEALTH HISTORY

Has your child experienced or is currently experiencing any of the following conditions:

Please be sure to fully explain any conditions your child is currently experiencing. It is important to include ALL information regarding your camper's history of illness so that our staff are prepared in case of incdent or emergency.

ACTIVITY RESTRICTIONS/OPERATIONS/HOSPITALIZATION/SERIOUS INJURY:

Camp Misawannee is located on a rugged, wooded site (all 3 locations), most activites take place outdoors. Does your child have any restrictions on activity? Has your child been hospitalized, had any operatons or had a serious injury? If yes, please explain giving details, date of occurance, any lingering effects on child's health, and any information that staff should be aware of:

Is there anything you would like to discuss with the camp medical staff?

IMPORTANT REMINDERS & WAIVER - please read carefully!

I understand that all information collected will be used to diagnose, treat or maintain my child's physical or mental health and to assist in preventing disease or injury or to promote health. This information is considered to be confidential and will be shared amongst health care providers as needed. ie: Camp Director, Camp Nurse, First Aid Attendant, Camp Counsellor. Walk in Clinic or Emergency Health Care Providers. This information will only be shared with the Camp Director and Camp staff on a need to know basis to ensure the physical and mental health of. my child.
To the best of my knowledge, my child is in good health. I will notify the camp in writing prior to arrival if there is any change in my child's health, or she is exposed to any communicable disease within 3 weeks prior to arrival at camp.
I agree to reimburse the camp for any prescriptions or medical expenses incurred for this camper.
I will submit any changes to this health form in writing to the camp prior to arrival.
At each camp there will be medical staff as follows:
- Day Camps in July will have a Level 2 Certified First Aid Attendant on site for the duration of the camp.
- Overnight Victoria Camp will have a First Responder on site for the duration of camp.
- August Overnight Camp will have a Registered Nurse on site for the duration of camp.

Photo Release: I give permission for photos of my daughter to be used for future promotion of the camp.

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 responsible 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 within the course of their duties. I further consent to the transportation of my daughter from the camp to the nearest hospital or clinic.

Which camp will your daughter be attending?

Day Camp July 4 & 5

Day Camp July 7 & 8

Victoria Overnight July 12-13

Overnight August 9-14

Signature of Parent/Guardian

Dated: