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Medeba.com

THIS FORM IS REQUIRED: Please Return
Up to three weeks prior to your camp sessions: Please mail: PO Box 138, West Guilford, ON, K0M 2S0
Within three weeks of your camp session: Please DO NOT MAIL; bring on registration day.
Camper Personal Information
Name:______________________________________Dates Attending:_______________________ Year:____________ Address:_______________________________________________________City/Town:__________________________ Province:_________________Postal Code:____________Date of Birth:______,______,_______Gender: M F Health Card Number:__________________________________________________ Version Code:______________
Emergency Contacts
Emergency Contact:________________________________________ Phone: (____)________________ Emergency Contact:________________________________________ Phone: (____)________________ Camper Health History
Please check if a camper had, or double check if a camper is currently experiencing any of the following: ___ADD or ADHD ___Epilepsy/Seizures ___Hepatitis ___Bedwetting ___Fainting/Dizziness ___Homesickness ___Chicken Pox ___Headaches (frequent) ___Nosebleeds (frequent) ___Skin Conditions (ex. eczema) ___Colds (frequent) ___Hearing Difficulties ___Mumps ___Ear Infections ___Heart Condition ___Stomach Aches (frequent) ___Measles ___Other__________________________________________________________________________________________ Ashthma: ___YES ___NO If yes, please indicate severity: ___MILD ___MODERATE ___SEVERE
If your child has had any of the previous, please give details as needed. Does it affect their ability to participate in any camp activities? If so, how? ____________________________________________________________________ __________________________________________________________________________________________________ Over the Counter Medications
Please check off any over the counter medications that your child CAN NOT take if needed.
Please note that the Health Centre supplies all listed medications so campers do not need to bring their own.
All medication dosages are given according to age and are given as per standing orders by a physician.
□ Advil (Ibuprofen)
□ Pepto-Bismol (Bismuth Subsalicylate) □ Throat Lozenge (Hexylresorcinol) □ Sudafed (Pseudoephedrine Hydochloride) □ Benadryl (Diphenhyramine Hydrochloride) □ Cough Syrup (Dextromethorphan Hydrobromide) Camper Allergies
Please check YES or NO for each and indicate severity of the allergy. MANDATORY:
For allergies that are life-threatening or next page→
Medications
Please list the medications (including vitamins) that the camper will be taking while at camp. All medications and vitamins, including over the counter medications (see above for those provided by the Health Centre), are to be kept in the Health Centre and administered by Medeba staff with the exception of inhalers which may be kept on the camper’s person. If medications are administered by injections, the camper must be able to self-administer with supervision. Please note that all vitamins and medications must be in their original pharmacy containers or they will not be administered. Medication __________________________________ ___________________________ ________________________________ __________________________________ ___________________________ ________________________________ __________________________________ ___________________________ ________________________________ __________________________________ ___________________________ ________________________________ Immunization History
Up to Date? □ YES □ NO Please provide dates if possible below:
DTaP (Diptheria, tetanus, pertussis, polio): ______________ Hib (Haemophilus influenza type B):_______________ Hepatitus B: ________________ Men-C:________________ For females over 9, HPV:________________________ MMR (Measles, Mumps, Rubella): ______________ Varicella:______________ Flu Shot:_______________________ Additional Information
Please provide in the space below any additional information about the camper’s health that we need to be aware of. Please include any special treatments, recent injuries or illnesses, or any considerations regarding care of the camper. Please attach additional information if needed. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Consent to Treatment
(Please note: This section must be read and signed by a parent/guardian in order for the child to remain a camper at Medeba.)
-To the best of my knowledge, my child is in good health. If my child becomes exposed to any serious/ infectious disease within four weeks of
attending camp, I will notify Medeba.
-In case of surgical emergency and I am not available for consultation, I hereby give permission to the physician selected by the Summer
Camp Director or designate to hospitalize, secure proper treatment for and to order injections, anesthesia, or surgery for my child.
-I give permission for Summer Camp Health Personnel and trained personnel to administer stock medications that are approved by a physician
in case of minor injury, and/or illness during my child’s stay at Medeba. I may request this list of stock medications and specify medication not
to be given. I also give permission for Summer Camp Staff to provide Standard First Aid to my child as appropriate.
-I give permission for Summer Camp Health Personnel and trained personnel to administer medications provided by me as per indicated on
this form.
-I give permission for Epinephrine to be administered as ordered by physician to my child in case of an anaphylactic (serious allergic) reaction.
-I agree that all the information given on this form is correct and complete.
-By providing my personal information and signing the form, I understand and agree with Medeba’s privacy policy as outlined at
www.medeba.com/privacypolicy.html.
-By signing, I agree to pay all health related expenses and treatments not covered by the Provincial Health Plan (ie. lice treatments, medica-
tions, dressing supplies, etc.)
Parent/Guardian Signature____________________________________________ Date______________________

Source: http://www.medeba.com/PDFs/Camper%20Health%20Form%202013.pdf

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