CAMP SHOMRIA HEALTH HISTORY AND MEDICAL PERMISSION FORM
Personal Information

MEDICAL INSURANCE   (non-resident of Ontario)

Please note – for out of country campers, a valid Visa card number is necessary for your child to be treated by a physician either in a doctor’s office or hospital emergency room.

EMERGENCY CONTACT other than parents: 

Please note that this person must be available while your child is at camp

MEDICAL DATA:   

CAMP SHOMRIA HEALTH HISTORY AND MEDICAL PERMISSION FORM

My signature on this form indicates that the information is correct and that I agree to the following:
·      My child is in good health and is physically able to participate in all camp activities unless otherwise indicated. All medical, social-emotional and behavioural problems or conditions requiring ongoing supervision or care have been adequately identified and described.
·      My child has not been exposed to any infectious disease during the past four weeks. If s/he becomes exposed to any infectious disease between now and the time of departure for camp I know that the camp office must be notified immediately.
·      In cases where the camp medical staff requires either consent for treatment or additional information, a parent will be contacted. If a parent cannot be reached, permission is hereby given to Camp Shomria to take whatever steps it deems necessary to ensure the safety and health of my child.
·      I provide Camp Shomria permission to both share information and receive information on my child’s behalf from and with appropriate health care providers in order to obtain/provide necessary medical care. This includes my child’s physician and physicians and nurses in the local hospital/medical centre.
·      The medical information contained in this form will remain confidential to the camp medical staff. The information will be selectively shared at the discretion of the Registered Nurse so that appropriate health care can be provided, both in an emergency and on a daily basis at camp.
·      In case of emergency, and/or if a parent or designated emergency contact is not immediately available for consultation, consent is hereby given to a physician selected by the Registered Nurse or a staff member of Camp Shomria to provide or obtain appropriate medical and/or surgical care as deemed necessary.
·      It is understood and agreed that the Camp Medical Staff has permission to act on behalf of a parent to engage in medically necessary service, including attention at the local hospital. A parent will only be contacted with a health issue at the discretion of the Nurse. It is also understood that the Nurse or her designate will dispense prescription and non-prescription drugs in accordance with accepted nursing practice.
·      If there are, or have been pre-existing medical, social-emotional or behavioural concerns that become problematic at camp, the Medical Staff will act to address the safety of my child and to promote the well-being of all.
·      I have clearly identified any and all medical, social-emotional and behavioural concerns and provided information on this form about medications and/or strategies that can be used by camp staff for dealing with these. I understand that if I have not adequately identified both concerns and strategies and if these become problematic during the summer, Camp Shomria maintains the right to send my child home at my expense and without a refund.
·      If a medical, social-emotional or behavioural problem develops that cannot be handled effectively at camp, it is understood and accepted that my child may be sent home. Camp Shomria is not equipped to provide programming for children with special needs.
·      Cigarettes, alcohol and drugs are absolutely forbidden at camp. Use of these will result in my child being sent home at my expense and without a refund of fees.