Kids Sports Camp Medical Form

Camper's Name *

First

Last

Camper's Date Of Birth (YYYY/MM/DD) *

Camper's Health Card Number *

Please include the 2 letters

Parent(s)/Guardian name

Camper's Home Address *

Address 1

Address 2

City

Province

Postal Code

Canada

Country

Parent(s)/Guardian Home or Cell Phone Number *

Parent(s)/Guardian Work Phone Number *

Parent(s)/Guardian Email *

Camper's Emergency Contact Name *

Camper's Emergency Contact Phone Number *

Camper's Family Physician *

Camper's Family Physician Phone Number *

Camper's Family Physician Address (Clinic Name, Street, City) *

Please list the camp/week(s) that your child is registered for *

Allergies (please specify)

e.g. peanut, tree nut, lactose, eggs, bees

Medical Conditions (please specify)

e.g. Asthma, Diabetes, etc.

Special Needs (please specify)

e.g. ADD/ADHD, Autism, etc... Please note that we DO NOT HAVE insurance coverage for ONE-TO-ONE CARE. We are working on this and hope to provide it in the future.

Other Needs

Does you child have any other physical, emotional, mental, behavioural concerns or limitations, not listed above that camp staff should be aware of?

Medications at Camp (please specify)

Please list any medications that camper may need e.g. EpiPen, Inhaler. Please note that staff and volunteers are not able to administer medication. Arrangements can be made for guardians to administer if needed.

Release and Waiver of Liability *

Yes, I agree
No, I do not agree

The safety of your child is our primary concern. Precautions will be taken for their well-being and protection. I/we, the undersigned parent(s) or legal guardian of the child listed above, hereby authorize: the Camp Director and/or the Camp Leads of Port Church Kids Sports Camp to sign/give consent to a physician or medical practitioner, to hospitalize, or secure proper treatment including but not limited to the prescription of medications, diagnostic studies, and any other medical procedure for my child as deemed necessary by the physician under the circumstances. It is understood that this authorization is given in advance of any specific medical treatment being needed, and is given to provide authority to the physician to render that care which in exercise of his or her best judgment is advisable. I/we, named below, undertake and agree to indemnify and hold harmless, the director, staff and volunteers of Port Church from any injury, loss or damage to any person or belongings, incurred while at the Camp. I also understand that the use of Port Church's facilities is made strictly at the risk of the applicant and agree to abide by the regulations governing Port Church.