2025 MEDICAL WAIVER | Camp Misawannee

CAMP MISAWANNEE

MEDICAL WAIVER FORM

CAMPER OR STAFF DETAILS

Please indicate whether you are filling out this form for a staff member or a camper.

Camper

Staff Member

First name

Last name

Phone (CELL)

Birthday

Year

Month

Day

Personal Health Number (PHN)

Multi-line address

Country/Region

Address

City

Zip / Postal code

PARENT CONTACT INFORMATION

For Campers ONLY please complete parent information.

Parent Name

Parent Cell Number

Parent Email

EMERGENCY CONTACT INFORMATION

Emergency Contact

Emergency Contact Cell Number

Relation to Camper

CAMPER HEALTH INFORMATION

Family Doctor

Doctor Phone Number

Family Dentist

Dentist Phone Number

DIETARY RESTRICTIONS

ALLERGIES / EPI-PENS

Do you have allergies?

YES

List any other allergies not shown:

Do you require an EPI-PEN?

YES

If yes, please provide details about your anaphylaxis.

If you are required to carry an EPIPEN (i.e. bee/wasp allergy), please provide two non-expired EpiPens; one for you to carry and one to keep in the Health Centre.

ASTHMA / INHALERS

What are the triggers for your asthma attacks?

If you will be carrying a puffer with you, please bring an extra non-expired puffer to be left in the Health Centre.

MEDICATIONS AT CAMP & HOME

Will you be taking any medications while at camp (prescription or homeopathic)? If yes, list medications, dosage, schedule, route and reason for medications:

Does you regularly take any medications that will NOT be taken at camp? Will you require any treatments while at camp? If yes, please elaborate:

***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, your name, dosage, schedule, route and date. If any over-the-counter medications are sent to camp with you, they must be in the original package and left with the Health Care Staff.***

OVER-THE-COUNTER MEDICINE AT CAMP

May the following over-the-counter medications be given to you while at camp, if deemed necessary by the nurse or first aid attendant? Select those you will allow (if necessary):

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

HEALTH HISTORY

Activity Restrictions/Operations/Hospitalization/

Serious Injury

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

Please list concerns here:

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 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, I am in good health. I will notify the camp in writing prior to arrival if there is any change in my health, or if I am 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 First Aid Attendant on site for the duration of the camp.
- August Overnight Camp will have a Registered Nurse and a First Responder on site for the duration of 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.

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