2013 OLYMPIA HEALTH FORM
MUST BE INCLUDED WITH APPLICATION FORM IN ORDER TO COMPLETE REGISTRATION PROCESS
WEEK
SPORT
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Circle week(s) and print program(s) attending:
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CAMPER NAME______________________________ BIRTHDATE______________ AGE_____ WT._____
ADDRESS_____________________________________________CITY______________________
PROVINCE_________ POSTAL CODE_____________
HEALTH CARD #
Immunization up-to-date_______ Date of last booster____
Name of Parent / Guardian
HOME #
CELL #
WORK#
ALLERGIC REACTIONS **IMPORTANT**
Use back of form for explanation of severity and treatments
j Allergic to Penicillin__________ j Allergic to other medications____________________
j Allergic to bees / hornets / wasps _________________ j Other insects_____________________
j Allergic to food____________________________ j Other__________________
DIETARY REQUIREMENTS
j VEGETARIAN
j GLUTEN FREE
EPI-PEN _______
j LACTOSE FREE
Dietary requests - Medical or Religous only.
Any multiple food allergies or special diets need to be discussed with office staff prior to registration.
Parents may have to provide some food items for a camper with multiple food allergies.
CAMPER HEALTH HISTORY Check if your child experiences any of the following.
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Chicken Pox
Red Measles
German Measles
Mumps
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Appendicitis
Tonsillitis
Frequent Colds
Ear trouble
j Seasonal allergies
j Stomach aches
j Headaches
j Bedwetting
j Fainting
j Homesickness
j Sleepwalking
j ADD/ADHD
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Asthma
Diabetes
Epilepsy
Heart Conditions
PLEASE USE BACK OF FORM to explain health issues, emotional or physical limitations, learning disabilities,
ADD, social challenges or other information to ensure camper's safe and healthy week. Include all medication that
camper is taking and treatments. Prescription medication must have camper's name, name of medication, dosage
and time to be given on label. Medications brought to camp must be in original packages.
Medications must be handed to the Health Centre in a Ziploc bag, labelled with camper's name.
To the best of my knowledge my child is in good health. I will notify the camp if my child is exposed to any infectious diseases
during the three weeks prior to camp. In case of medical emergency, I understand every effort will be made to contact parents
and or guardian. In the event I cannot be reached, I hereby give permission to the Physician selected by the Camp Director to
secure treatment, hospitalize, order injections, anaesthesia or surgery for my child named above.
Signature of Parent / Guardian______________________________________ Date __________________
CAMPER'S NAME_________________________________
The Health Form needs to be included with the application form in order to complete the registration process.
FYI - If your child needs a prescription while at camp,
payment is required before they go home. You are able to pay by Credit Card
or the cost can be deducted from your child's Tuck Account.
Parents will be notified. Thank you.
PLEASE ADD ADDITIONAL INFORMATION ABOUT YOUR CHILD ON THIS PAGE.......