Medical Form - Camp Agudah Toronto

My role at camp*

Staff Member
Day Camper
Employee
Visitor

I will be at camp: (check both if you will be at camp both seasons)*

Girls Season
Boys Season

Name

First Last

Name (as it appears on health card)

First Last

Where I am a resident*

Ontario
Quebec
Out of Country

Email to send confirmation to*

Ontario Health Card Number

Version Code

Expiry Date

Quebec Health Card Number

Please upload a clear picture of your card ie ohip, valid Canadian insurance/private insurance

Accepted file types: jpg, gif, png, Max. file size: 256 MB.

Insurer*

Policy Number*

Physician's Name

Physician's Phone Number

Allergy Information

Camper/Staff has an allergy*

Yes
No

Allergies

Nuts/Peanuts
Insect Bites/Animals/Plants
Laundry Detergents/Softeners
Penicillin
Sulfa
Aspirin
Other foods
Other drugs

Please explain nut allergy

Is an epipen required?

Please explain Insect Bite/Animal/Plant allergy

Please explain Laundry detergent/softeners allergy

Please explain food allergy

Please explain drug allergy

Immunization Record

Please check whether the camper/staff has had any of the following:

Chicken Pox
Hepatitis
Measles
Mumps

Date of most recent MMR

Date of most recent DPTP

Please indicate if treatment for the following is required

Please list any medications and dosages being used to manage any of the above conditions or any other medications being brought to camp.

Press the + sign at the end of the row to add more

Camper/staff has been admitted to the hospital or seen by a doctor in the last 6 months other than for a routine physical*

Yes
No

For what reason?

The camper or staff has been taking medication in the past 6 months that could affect their wellness in camp

Yes
No

Please explain

Camper has been checked for lice/nits before camp

Yes
No

Does the camper/staff have any learning disabilities? (ex. ADHD)

Yes
No

Please explain

Does the camper/staff have any restrictions in regard to:

Diet
Swimming
Diving
Hiking

Please explain

Other restrictions

Previous Fractures

Please explain and list dates

OR Operations

Please explain and list dates

Does the camper/staff have a chronic recurrent illness?

Yes
No

Please explain chronic recurrent illness and suggested treatment

Are there any special conditions or circumstances that our medical staff should be aware of to assist us with the care of your child (eg. homesickness, bed wetting, phobias, nightmares, emotional or social concerns, etc.)

Yes
No

Please explain

Have there been any unusual behaviour changes or mood swings?

Yes
No

Please explain

Are there any family dynamics that may be a cause for concern for your child's well being? (ex. Death, illness, divorce, etc.)?

Yes
No

Please explain

MEDICAL WAIVER:

ONTARIO HEALTH MINISTRY REGULATIONS REQUIRE THAT THE FOLLOWING AUTHORIZATIONS BE COMPLETED AND SIGNED PRIOR TO ATTENDING CAMP.

This health history is correct as far as I know, and the person herein described has permission to engage in all prescribed camp activities except as noted by me on this application. I hereby give permission to the physician selected by the camp director and/or the medical staff to order x-rays, routine tests, and treatment for the health of my child. In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp directors or medical staff to hospitalize, secure proper treatment for, and arrange any surgery for my child as named on this form. I also grant permission for the camp or designated medical facility to contact the camper’s family physician or dentist for information. Please inform your physician and dentist that you have signed this authorization.

AUTHORIZATION TO CONSENT TO TREATMENT OF A MINOR TEMPORARILY SEPARATED FROM HIS/HER PARENTS

I/We the undersigned parents of*

a minor, do hereby authorize Camp Agudah and/or Rabbi M. Blaustein director of the camp and/or medical staff, as our agent(s) to consent to any diagnostic procedure or medical care which is deemed advisable by, and is to be rendered under the general or special supervision of any licensed physician/nurse and/or surgeon at such licensed medical facility chosen by the camp, when such diagnoses or treatment is rendered at said medical facility. It is understood that the authorization is given in advance of any specified need for treatment, and is given to provide authority on the part of our aforesaid agent(s) to give specific consent to any and all such diagnoses, treatments, or hospital care which the physician in the exercise of his best judgment may deem advisable. This authorization shall remain in effect from June 27 - August 24, 2022 inclusive, the aforementioned camper’s session at Camp Agudah.

Signature of Parent (for the above two clauses)*

Parent's Name*

Parent's Waiver

By completing this application I hereby authorize Camp Agudah to take my child(ren) off camp grounds, to go on trips organized as part of the camping program. This may include swimming and/or boating activities. In addition my child(ren) may participate in any on or off ground activity organized by camp, including but not limited to land sports, aquatic activities, all boating activities including but not limited to motor boats and water skiing, ropes course, indoor activities, bicycling, hiking, cookouts etc. and I assume the inherent risk of such activities and camp programs. I will hold Camp Agudah and their staff, harmless in the event of injury or death or property damage or loss as a result of such activities. I also agree to abide by all the rules and regulations set forth in the application, parents guide and administration.

I have read and accepted the Waiver/Declaration and general agreement and agree to all terms and conditions.*

Staff Member's (Parent's Name for minor)*

Date*

Email to send confirmation to*