MEDICAL RECORD
Recent
photo
Thank you for taking the time to complete this questionnaire. Your detailed
answers will help us to better personalize the camper’s care and allow them
to have a more enjoyable stay with us.
To be accepted to the camp, the camper must have been in a stable
condition for at least 3 months. He/she must not have any sores that may
worsen during his/her stay at camp.
Please note that this information will remain CONFIDENTIAL and will be consulted only by the
AUTHORIZED personnel of the camp, and in case of emergency transmitted to the emergency response
team (ambulance and medical personnel).
CAMPER
Family name:
Gender:
First name:
Age:
M
F
Address:
Town:
Postal code:
Telephone:
Date of birth:
Health Insurance Card #:
Expiration date:
dd/mmm/yyyy
*A photocopy of the Health Insurance Card must be sent with this form.
PARENT(S) OR GUARDIAN(S)
Family name:
Family name:
First name:
First name:
Relationship:
Relationship:
Address:
Address:
(Home):
Telephone:
(Home):
(Work):
Telephone:
(Cell):
(Cell):
Email:
Custody of child:
Email:
Mother and Father
Mother
Do you anticipate being away during the camper’s stay?
Revised 22 January 2016
(Work):
Father
Shared
Yes
Guardian
No
Page 1 of 7
Name of camper: _____________________________________________________________
(Please print)
IN CASE OF EMERGENCY
Person to contact in case of EMERGENCY:
Mother and Father
Mother
Father
Guardian
OTHER person(s) to contact in case of emergency:
Family name:
Family name:
First name:
First name:
Relationship:
Relationship:
(Home):
Telephone:
(Home):
(Work):
Telephone:
(Cell):
(Work):
(Cell):
Family Doctor or other health professional:
Name of Doctor:
Telephone:
Clinic or Hospital:
MEDICAL DIAGNOSIS
Medical Diagnosis:
Physical disability, details:
Deaf or hearing impaired, details:
Blind or visually impaired, details:
Intellectual disability, details:
ALLERGIES
Does the camper have any known allergies?
Yes
No
Yes
No
If Yes, please specify…
Medication (Ex: Penicillin, etc.):
Food:
Insects/Animals/Other:
Please describe the type of reaction and treatment necessary:
Does the camper use an epinephrine auto-injector?
(Ex: EpiPen, Allerject, etc.)
Revised 22 January 2016
CAMP MASSAWIPPI
Page 2 of 7
Name of camper: _____________________________________________________________
(Please print)
HEALTH
Does the camper suffer on a regular or
permanent basis from any of the following:
Skin condition
Yes
No
Asthma
Yes
No
Bronchitis
Yes
No
Constipation
Yes
No
Diabetes
Yes
No
Diarrhea
Yes
No
Fever
Yes
No
Insomnia
Yes
No
Motion sickness
Yes
No
Heart disease
Yes
No
Headaches
Yes
No
Nose bleed
Yes
No
Sinusitis
Yes
No
Sleepwalking
Yes
No
Cough
Yes
No
Vomiting
Yes
No
If Yes, what is the usual treatment (medication or
other) and what special precautions should be taken?
Has the camper ever had a serious illness or surgery?
Yes
No
Yes
No
If Yes, please specify (date/details):
Has the camper ever had a seizure?
If Yes, when was the last occurrence?
How often do they occur?
Describe the seizure:
Revised 22 January 2016
CAMP MASSAWIPPI
Page 3 of 7
Name of camper: _____________________________________________________________
(Please print)
Does the camper have a shunt?
Yes
No
Yes
No
If Yes, describe any specific care or concerns related to the shunt:
Date of the camper’s last immunizations:
Tetanus (T)
Date:
Hepatitis B
Date:
Has the camper had Chicken Pox?
MEDICATION
Please include in the table below ALL MEDICATION to be administered to the camper while at camp.
We rely on your cooperation to send us all necessary medicines (including Tylenol ®, Advil®, vitamins, etc.)
in their original containers, with the pharmacist’s label for prescription drugs.
We strongly recommend that you ask your pharmacist to prepare a 'DISPILL' to avoid any
confusion.
(Please print)
Name of Medication
Dose (mg)
Time/Frequency
Method of Administration
Breakfast
Lunch
Supper
Bedtime
Other:
Breakfast
Lunch
Supper
Bedtime
Other:
Breakfast
Lunch
Supper
Bedtime
Other:
Breakfast
Lunch
Supper
Bedtime
Other:
Breakfast
Lunch
Supper
Bedtime
Other:
Revised 22 January 2016
CAMP MASSAWIPPI
Page 4 of 7
Name of camper: _____________________________________________________________
(Please print)
Continued…
Name of Medication
Dose (mg)
Time/Frequency
Method of Administration
Breakfast
Lunch
Supper
Bedtime
Other:
Breakfast
Lunch
Supper
Bedtime
Other:
Breakfast
Lunch
Supper
Bedtime
Other:
Breakfast
Lunch
Supper
Bedtime
Other:
Breakfast
Lunch
Supper
Bedtime
Other:
Breakfast
Lunch
Supper
Bedtime
Other:
Breakfast
Lunch
Supper
Bedtime
Other:
Breakfast
Lunch
Supper
Bedtime
Other:
Breakfast
Lunch
Supper
Bedtime
Other:
Breakfast
Lunch
Supper
Bedtime
Other:
Revised 22 January 2016
CAMP MASSAWIPPI
Page 5 of 7
Name of camper: _____________________________________________________________
(Please print)
MEDICAL CARE
FEEDING
Does the camper require gavage (tube) feeding?
Yes
No
Yes
No
Yes
No
If Yes, how many times per day?
What time:
Quantity:
Description:
ELIMINATION
Does the camper need to be catheterized?
If Yes, how many times per day?
What time:
If Yes, do they require assistance?
Description:
To prevent constipation, describe the camper’s daily regular habits:
(Ex: Prune juice, All Bran, etc.) Any laxatives, suppositories or enemas should be listed in the Medication Table
Does the camper require disempaction (manual extraction)?
Yes
No
If Yes, do they require assistance?
Yes
No
Description:
Once per day
Twice per day
If Yes, how many times per day?
SKIN CARE
Does the camper’s skin need checking regularly?
Yes
No
If Yes, please specify:
Revised 22 January 2016
CAMP MASSAWIPPI
Page 6 of 7
Name of camper: _____________________________________________________________
(Please print)
OTHER COMMENTS
AUTHORIZATION OF PARENTS/GUARDIANS
I hereby authorize that__________________________________________________________________
(Name of camper)
may be examined and/or treated by the nursing staff of Camp Massawippi and if necessary by a doctor or
health professional of a regional hospital or clinic.
I hereby authorize the staff of Camp Massawippi to administer medication to my child, if required.
I also authorize the administration of Camp Massawippi to undertake any and all necessary emergency
measures and decisions required on behalf of the camper.
I agree to assume the cost of any medical treatment or purchase of medications for the camper.
I certify that the camper has been in a stable condition for at least 3 months.
I certify that the camper does not have any sores that may worsen during his/her stay at the camp.
Full name of parent or guardian: _________________________________________________________
(Please print)
Signature of parent or guardian: __________________________________________________________
Date _________________________________________ 2016.
Camp Massawippi staff will inform parents or legal guardians, as soon as possible, of any necessary
interventions which are outside the camper’s regular and daily care.
Revised 22 January 2016
CAMP MASSAWIPPI
Page 7 of 7