Camp MacLeod

Albert Bridge, NS
Text Box: Medical Form Text Box: CAMP MACLEOD – CAMPER HEALTH FORM Camper’s Name: _________________________________________________ Camp _____________ Last First Middle Initial Health Card Number: _______________________________________ Date of birth: _____________ DD / MM / YYYY Contact Information Parent/Guardian: __________________________________________ Relationship to camper ________________ Home Phone # ____________________________________________ Work Phone # _______________________ Home address: __________________________________________________________________________________ Other Emergency Contact: ________________________________ Relationship to camper ________________ Home Phone # _________________________________________ Work Phone # _______________________ Family Doctor: __________________________________________ Phone # ____________________________ Please note if your camper is subject to any of the following, and explain on the back of this form: ð Asthma ð Diabetes ð Sleep walking ð Hyperactivity ð Shyness ð Ear infections ð Kidney disease ð Bed wetting ð ADD/ADHD ð Fear of dark ð Sore throat ð Heart disease ð Nightmares ð Epilepsy ð Nose bleeds ð Frequent colds ð Eye trouble ð Stomach troubles ð Headaches ð Bronchitis ð Fainting ð Constipation ð Migraines If your camper has had any other operations or serious injuries please explain: ___________________ Does your camper have any known allergies? Yes or No If yes, please explain: Allergy to: Describe reaction and treatment ð Drugs ____________________________________ _________________________________________________ ð Food ____________________________________ _________________________________________________ ð Insect Stings ______________________________ _________________________________________________ ð Other ____________________________________ _________________________________________________ Please note: To care for your child to the best of our ability, please describe any other physical, emotional or behavioral problems _______________________________________________________ Has this person been exposed to or suffered from any infectious disease during the three weeks prior to the first day of camp? For example: German Measles, Measles, Chicken Pox, Mumps, Tuberculosis, Whooping Cough, H1N1, etc. Yes or No If yes, please call the Camp Director before coming to camp. Date of last immunizations: ________________________________________________________________________ My Daughter has been informed about menstruation: Yes or No Does your camper receive any medication? Yes or No If yes, please explain:  All medication must be given to the Director in the original package from the pharmacy on opening day! Recent changes in Family (death, illness, divorce, etc) ___________________________________________________ NOTE: You and your doctor are responsible for the health of your camper; this form should clearly indicate their health status. The camp staff will do their utmost to contact the family if an emergency arises; however, the signature on this form signifies that permission is granted for camp staff to arrange for medical attention with a local doctor and for that doctor to provide any necessary treatment and that having taken such precautions as in the discretion of Camp MacLeod as are deemed advisable, Camp MacLeod shall not be held responsible for any accident or illness involving my child. Signature of Parent/Guardian _____________________________________________ Date _____________________ All information in this form is confidential.