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Camper Information Sheet:

ParticipantsFirstname: MICHAEL
ParticipantsLastname: MARK

Emergencycontactname: KATHERINE MARK


HomePhone:
WorkPhone:
Cellphone: 613-807-9538
Relationshiptocamper: MOTHER

Emergencycontact#2(NOTAPARENT)Name: JANE CLARK


Homephone:
Workphone:
Cellphone: MICHAEL

Relationshiptocamper: NANNY

NO
Arethereanyexistingcustodyissues?__________________________________________________________

Pleaseprovidethenamesofanyonewhomaybesigningthecamperoutattheendoftheday:

Person(s) Relationship Monday Tuesday Wednesday Thursday Friday


allowedto tocamper: (Leave (Leave (Leave (Leave (Leave
pickup: blank)
blank) blank) blank) blank)


KATHERINE
MARK MOTHER
ASHLEY FATHER
MARK

JANE CLARK NANNY



**Reminder:AnyonepickingupacampermustprovidephotoID**
Medical Information Sheet:

ProvincialHealthCardNo.:(IffromoutsideCanadaMedicalPlan#)
PROKOPIAK (613) 836-5083
Doctorsname:Doctorsphonenumber:

MedicalInformation

Isthecampercurrentlyunderthecareofaphysician?YesNo
Ifyes,pleaseprovidedetails:

Doesthecamperhaveanyallergies?YesNo
Ifyes,pleaseprovidedetails:

Hasthecamperexperiencedsymptomsofacommunicablediseaseinthepast3weeks?YesNo
Ifyes,pleaseprovidedetails:

Hasthecamperreceivedpsychological,groupcounselling,orpsychiatrichelp?YesNo
Ifyes,pleaseprovidedetails:

HasthecamperreceivedallimmunizationsrecommendedbytheOntarioMinistryofHealth?YesNo
Ifno,pleaseprovidedetails:

MyMedicalRecord

WhatImusing Dosage How&whentouse WhyImusing/Notes


(Rxbrand&generic (Howmuchtoadminister (e.g.Takeorally,two (e.g.lowersblood
name;OTCname& e.g.40mg,2smallpills) timesperdaywithfood pressure)
activeingredient) @9AM&6PM)

Icertifythatallinformationprovidedonthisformisaccurateandcomplete(attachadditionalsheetsif
required).

Parent/guardiansignature:

Date:CampDirectorsignature: