Camper Information Form - Residential Camp 2008

Camp Dates : _________________________ Programme Name:___________________

Note: This information is being collected in accordance with privacy legislation and will be used solely for the purpose of providing medical care and support during the camp programme.

Camper Information

Name _________________________________________________________________

Address ____________________________City_________Postal Code_____________

Birth Date Y_____M_____D_____ Age______ Sex ______ Height _____Weight______

Swimming Ability or Highest Level Achieved __________________________________

Alberta Health Care Number ________________________________________________

Do you have additional health coverage?    Yes or   No

If yes - provider's name and plan number_____________________________________

Have you been to camp before?    Yes  or   No

If yes, how many times? _______ Which ones? ________________________________

Emergency Contacts

                                    Parent(s)/Guardian(s)               Alternate Contact

Name               __________________________   __________________________

Day Phone      __________________________   __________________________

Eve Phone      __________________________   __________________________

Relationship   __________________________   __________________________

Camper Resides with: Mother Father Other __________________________

Family Doctor _____________________________ Office Phone _______________

Medical Information

Please note: We recommend that you visit your doctor prior to arrival at camp to check your physical condition. If medical conditions change, please inform the camp office.

Are there any prescription drugs you would like senior staff to administer? Yes or No

•  If yes, supply medication in original packaging or bubble packing, state the camper's name, medication name, dosage, time of administration, side effects

•  Note: Campers may not administer their own drugs.

Will you be discontinuing any prescription drugs during your visit?   Yes  or No

  If yes, which drugs?________________________________

May Senior Staff administer Tylenol, if required:   Yes  or  No

Do you have any adverse reactions to Tylenol?     Yes  or No

What is the longest period of time you have been away from home? _______________

 












Consent for Medical Treatment and Release of Information

We, the undersigned participant, parent or guardian, understand the above information is collected in accordance with privacy legislation. In signing this form, I give permission for the above information to be used for the sole purpose of providing medical care and support for the duration of the camp programme.

I acknowledge that in the event of an emergency, treatment may be provided to myself or my child by a physician selected by the YWCA Edmonton and that I will be financially responsible for any costs associated with such treatment and services, such as ambulance service.

I understand that it is my responsibility, as parent or guardian of my child, to inform the YWCA Edmonton of any medical or health concerns that may affect my child's participation in camp programmes and related events and activities.

Date Signed:            __________________________

Participant:              _________________________________________________

                                  Print Name                               Signature

Parent/Guardian:   _________________________________________________

                                Print Name                       Signature

Audio/Visual Recording Consent

We, the undersigned participant, parent or guardian, hereby acknowledge that the YWCA Edmonton may use, reproduce or distribute any photographs, slides, video or other similar material associated with the Programme and related events and activities for promotional and archival purposes. There is no time limit to this consent, however, the consent can be revoked at anytime with written notice to the Manager of YWCA YoWoChAs Outdoor Education Centre. Audio and visual recordings will be securely stored at YWCA YoWoChAs Outdoor Education Centre.

Date Signed:            __________________________

Participant Name:   ________________________________________________

                                  Print Name                                 Signature

Parent/Guardian:   _______________________________________________

                                 Print Name                                   Signature

YWCA Edmonton - YoWoChAs Outdoor Education Centre

NOTIFICATION & UNDERSTANDING OF RISKS FORM

For Participants Under The Age Of 18 Years

Note: If this form is not complete, your child will not be permitted to participate in camp activities .

We, the undersigned participant, parent or guardian, are aware that participation in YWCA YoWoChAs Outdoor Education Centre programmes (the "Programme") involves inherent risks, dangers and hazards, including, but not limited to:

•  all manner of injury or loss, including potentially serious or life-threatening injury and death, resulting from the use of equipment, materials or facilities related to the Programme and it's events and activities;

•  all manner of injury or loss, including potentially serious or life-threatening injury and death, resulting from forces of nature, accident, hazards of participating in outdoor activities and sports including activities and sports taking place on or near water, illness, allergic reactions and all other manner of injury related to the Programme and its events and activities;

•  all manner of injury or loss, including potentially serious or life-threatening injury and death, resulting from the actions or negligence of other participants in the Programme and related events and activities; or

•  additional risks, injury or loss, including but not restricted to unforeseen additional risks, injury or loss arising out of the Programme and related events and activities.

We, the undersigned participant, parent, or guardian, are aware of these risks, dangers and hazards and the possibility of injury, death, property damage, property loss or other loss or expense resulting to my child or myself.

In consideration of being allowed to use the equipment, materials and facilities of the YWCA Edmonton and being allowed to participate in any way in the Programme and related events and activities at the YWCA Edmonton, we the undersigned participant, parent or guardian, hereby agree as follows:

•  TO ABIDE BY or to inform my child that he or she is to abide by the rules and regulations including directions and instructions from YWCA staff and in the event that there is a failure to do so, I agree that my child may be excluded from further participation in the Programme and that I may be contacted to have my child picked up and removed from the Programme;

•  That this Agreement will be effective and binding upon myself, my child, our heirs, next of kin, executors, administrators and assigns in the event of myself or my child's death.

We, the undersigned participant, parent or guardian, hereby acknowledge that we have read the foregoing, and, in the case of parent or guardian, have explained its meaning to our son, daughter or ward.

We acknowledge that we understand the content, importance and meaning of the Notification and Understanding of Risks form and hereby do approve and consent to the above and give permission for my child to participate in activities at YWCA Edmonton YoWoChAs Outdoor Education Centre.

Date Signed:           __________________________

Participant Name:   _________________________________________________

                            Print Name                         Signature

Parent/Guardian:   ________________________________________________

                            Print Name                           Signature

Summer Camp Special Needs Supplement 2008

Please use this form, in addition to the attached camper information form, to provide our staff with information about your child and his/her special needs. Both forms should be returned to our office a minimum of five days prior to your child's stay at camp.

All information you provide to us will be used to provide appropriate care for your child and will remain in strict confidence. Please contact our office at 780.892.2660 for more information. Attached additional sheets if required.

Camper's Name: __________________________________________________

Programme Name: _____________________   Session: ___________________

Please describe special needs: _______________________________________

  _______________________________________________________________

  _______________________________________________________________

  _______________________________________________________________

Please describe any special equipment or aids required: ____________________

________________________________________________________________

________________________________________________________________

________________________________________________________________ 

Please describe any assistance required with independent living skills

(i.e. personal hygiene, eating, dressing, etc…):

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________ 

Please describe additional or specialized supervision required: _______________

________________________________________________________________

________________________________________________________________

________________________________________________________________ 

Please describe effective behaviour management techniques: _______________

_______________________________________________________________ 

_______________________________________________________________

_______________________________________________________________ 

If medication is required, please fill out the following chart. Write medication in the appropriate box including specific time and dosage required.

Is there additional information that will help us to provide a successful camp experience? ______________________________________________________

________________________________________________________________