Cadre de référence

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

Source: http://centremeredith.ca/wp-content/uploads/2013/02/Health-sheet_2.pdf