Medical Form
(required for 14 years and under)
Please Print
Name: __________________
Address:_______________________
City: ______________ Postal Code: _________ Home Phone: (___)
_______
Birth Date: (Y/M/D) :___________________ Health Card #:_______________
Name of Parents/Guardians: 1.
______________________________________________________________
Day Phone: (_____) ______________ Evening Phone:
(_____) _________
2.
______________________________________________________________
Day Phone: (_____) ________________ Evening Phone:
(_____) ________
Alternate Emergency Contact (neighbour, grandparent, etc.)
Name:_________________________ Relationship:
___________
Home Phone: (_____)
_________________ Work:
Phone: (_____) _______
Health Information: List / attach all
medical information, even if discontinued for the summer.
______________________________________________________________
Family Physician Name:______________________ Phone: (_____)
________
*Note: Asthma:
An additional inhaler is to be left with
the staff for emergency use, (2 in total).
*Note: Bee, Wasp, Hornet allergy: An Epipen is required to be sent with
child.
Drug allergies or special conditions
(Specify):_______________________________________________________
List medication(s) and reason(s) for use:
Name of medication: ____________________ Dosage
& frequency:_________
Reasons for
use: _________________________________________________
Please provide any additional comments/information which you feel
may be useful to the Director & Counsellors in providing the
most positive of experiences for your child:
To the best of my knowledge my child,
____________________ is in
good health.
I will notify Down To Earth by phone and in writing if my
child is exposed to any infectious disease or has new medical
information, 3 weeks prior to arriving at workshop. In the case of medical
emergency, I understand every effort will be made to contact parents
or guardians.
I hereby give permission to the physician selected by
Down To Earth staff to hospitalise, secure proper treatment, order
injection, anaesthiesia or surgery for my child, named above.
Signature: ____________________ Name: _______________ Date:________
Remember to complete a registration form with your application.
Down To Earth