Meredith Centre Day Camp HEALTH SHEET Please return health sheet with the registration form. 1 sheet per child
1. GENERAL INFORMATION ON CHILD
2. EMERGENCY CONTACT 3. IN CASE OF AN EMERGENCY
Person to contact in case of an EMERGENCY : Father and mother Mother Father Tutor 2 other people to contact in case of an EMERGENCY : Ful name :
4. MEDICAL HISTORY
Has your child ever had a surgical procedure?
If so, Date : Reason : Serious injuries Chronic or recurrent disease
Has your child ever have the fol owing diseases?
5. VACCINES AND ALLERGIES
Does your child have any of the fol owing
Does your child carry an adrenaline kit (Epipen, Ana-Kit) in case of an al ergic reaction? Yes No SIGN HERE IF YOUR CHILD HAS AN ADRENALINE KIT In case of an emergency, I hereby authorize the Meredith Centre personnel to administer an adrenaline shot ________________________ to my child. ___________________________________________________ Parent’s signature 6. MEDECINE Does your child take any medication?
Does your child take medications on their own?
Yes No If your child must take medications, you must fil out a medication authorization form when you arrive at the camp so that day camp personnel can distribute the prescribed medication to your child.
7. OTHER PERTINENT INFORMATION The fol owing questions wil help us work with your child. Does your child need constant supervision in the water?
Does your child have any behavioral problems?
If so, describe : Does your child eat normal y?
If not, describe : Does your child wear any prosthetics?
Are there any activities that your child can not participate in or only
under certain conditions? If yes, explain : 8. OVER THE COUNTER MEDICATION
I authorize the Meredith Centre day camp personnel to administer one or more of the fol owing over the counter medications to my child if necessary. Check off the medication : acetaminophen (Tylenol, Tempra)
Other, specify : ____________________________
anti-inflammatory (Advil) Father or Mother's signature : __________________________________ Date : ____________________ Please note that all information concerning your child’s health condition will remain confidential. Information will be transferred only to the child's camp counselor and day camp coordinator in order to allow proper supervision and intervene efficiently in case of an emergency. 9. PARENT'S AUTORISATION
Since The Meredith Centre day camp wil be taking pictures and (or) videos during day camp
activities in which my child wil be participating, I al ow The Meredith Centre to use this material as a whole or in part for promotional purposes. Al material wil remain Meredith Centre day camp property.
If some modifications are required regarding my child’s health issues before or during day
camp hours, I agree to transmit this information to the day camp management, who wil fol ow up with my child’s camp counselor.
By signing this, I al ow the Meredith Centre day camp to administer first aid to my child. If the
Meredith Centre day camp management judges that it is necessary, I also al ow them to transport my child by ambulance or by another means to a hospital or any other heath care facility.
I wil col aborate with Meredith Centre day camp management and staff and wil meet with
them if my child's behavior impairs successful day camp operations.
______________________________________________ Ful name of parent or tutor _______________________________________________ _______/_____/________ Parent or tutor signature
Patient Procedure Guidelines Arm and Chest Port insertion and removal: (Ordering Physician) Send signed order specifying arm or chest port, history and physical, recent labs including platelet count, and list of meds to FAX 765-9955. Patient must be NPO for 6 hours prior to procedure in order to receive IV Conscious Sedation. Oral meds may be taken with water. Patient must bring driver an
Client Information DIRECTIONS FOR TREATING A SUSPECTED CHLAMYDIA INFECTION We recently treated your sex partner for chlamydia. It is a curable bacterial infection you can get from having sex with a person who has it. You are probably infected, too. Many people who have chlamydia do not know they have it. They often have no symptoms and feel fine. Others may feel pain. It can be in their p
Meredith Centre Day Camp