Health form

METOCHOS CAMP HEALTH INFORMATION FORM
The information on this form wil be used at the discretion of the camp staff to ensure care and attention is given to the health of this camper. All information is considered personal and confidential. Name: ___________________________________________ Parent/Guardian Name (s): ___________________________________________________________ If the above is unavailable in an emergency, please notify: _______________________________________________ Phone: Home ____________________ Work _____________________ Cell _________________ Address: _______________________________________________________________________ Provincial Health Number ________________________________ Other Health Insurance ___________________________________ Family Doctor __________________________________________ The camp program includes swimming, hiking, canoeing and many other physical activities. Does the applicant suffer any physical or emotional disorders that would prevent him/her from participating fully in our program? _____________ If so, please state issues: ________________________________________________________________________________________________________________________________________________________________________________ Are there special instructions for camp staff in regards to camper’s health care, diet, etc.? ________________________________________________________________________________________________________________________________________________________________________________ Does the camper have any ALLERGIC REACTIONS to such things as drugs, food, bug bites? If so, list, giving type of reaction and treatment. ________________________________________________________________________________________________________________________________________________________________________________ Is the camper subject to any of the following: ___Arthritis ___Convulsions ___Motion Sickness ___Respiratory ailments ___Ear troubles ___Nightmares ___Bed Wetting ___Headaches ___Sleepwalking ___Other (please indicate) __________________________________________________________________ Please give details of usual treatment should condition occur: ________________________________________________________________________________________ Chronic conditions of camper or recent il nesses off which staff should be aware: Please list any medication which the camper is bringing to camp. This must be clearly labeled with name and circumstances under the medication is administered to the camper, and given to the camp staff on arrive at camp. On occasion, campers become il at camp and require attention from our camp staff. Please indicate the non-prescription medications that the camp staff can administer to your child. (ie: Tylenol, Advil, Benadryl, Halls, Cough & Cold Medications, Child Strength Tylenol/Advil, etc.) Date of last tetanus shot? __________________________________________________________________ Are eye glasses required? ________________ Other comments or information on campers health?? ________________________________________________________________________________________________________________________________________________________________________________ EVERY CARE AND ATTENTION WILL BE GIVEN TO THE HEALTH & COMFORT
OF ALL PARTICIPANTS OF METOCHOS CAMP.
I hereby authorize, Metochos Ministries Lutheran Bible Camp Assoc. to secure such medical advice and services as may be deemed necessary for the health and safety of myself, my child, my ward. ______________________________________________ Signature of Applicant (if over 18) or Parent/Guardian

Source: http://www.metochos.ca/pdf/HealthInformationForm.pdf