Camper Health Information Form - Camp Wenonah

CAMP WENONAH
2013 Camper Information & Health Form
(Please return to the Burlington Office by April 26, 2013)
Camp Wenonah, 3584 Commerce Court, Burlington, ON, Canada L7N 3L7
CAMPER INFORMATION:
Camper / POLARIS / WCIT Name: _________________________________________________________ Male Female
Camper Health Card Number: _________________________________ Version Code: ____________________________
(A copy of your child’s Health Card must be sent to the Burlington office)
For Out-Of-Province Families: Campers must have Health Insurance to attend Camp Wenonah
Health
Insurance Plan & Number: ______________________________________________________________________________
Company Name: __________________________________________________ Phone Number: _____________________
Billing Address: _______________________________________________________________________________________
CABIN MATE REQUESTS (not applicable to POLARIS/WCIT participants):
NOTES: - requests are granted when campers are no more than 18 months apart in age
- we reserve to limit the number of requests to no more than two per camper
- requests must be made by BOTH campers/families
- two week campers will not necessarily be placed with one month campers
- one week campers will not be placed with two week or one month campers
- a non cabinmate request (both families must be made aware)
1. ____________________________________________________________________ AGE ___________________
2. ____________________________________________________________________ AGE ___________________
VISITOR’S DAY PLANS (for one month campers, POLARIS, & WCITs):
We will visit our child and remain in Camp (expected number of people for lunch ___________ )
We will pick our child up and take him/her out of Camp for the day
We will take our child out of Camp overnight
I will be unable to visit my child on the designated Visitor’s Day
I will be unable to visit my child on the designated Visitor’s Day, and herby give my permission for my child to leave Camp with
who is a: relative
________________________________________________
family friend
parent of another camper
**Any changes to Visitor’s Day plans must be communicated, in writing, to the Muskoka Office within 48 hours of Visitor’s Day**
CAMPER’S/POLAIRS/WCIT EMAIL ADDRESS - _________________________________________________
We would like to keep everyone informed of all the exciting news from Wenonah year round!
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WE WELCOME YOUR COMMENTS:
1. What can the Camp Wenonah staff do to provide the best experience for your child
2. What do you do when your child is upset How do you calm them down
3. Help us understand the social preferences of your child. Does your child most easily make friends with other children
who are (please check):
My child’s own age Younger Older Adult All ages
4. Are there any recent significant changes in family relationships that may affect your child while he/she is at Camp
(please check)
Birth Death Illness Separation Divorce Move Other
Please explain the nature of the change:
5. What are the eating habits of your child (please check)
Fussy Average Hearty
6. Is your child on a special diet (please check)
No special diet Vegetarian Does not eat red meat Other (please specify):
NOTES ABOUT FOOD SERVICE: Special diet alternatives are available, and MUST be pre-selected. Once selected, that is the
menu choice for EACH meal at Camp. No substitutes or switching will be allowed during the Camp Period(s) attending.
SLEEP HABITS:
7. a) Please help us understand your child’s sleep patterns. Check all of the following that apply:
Frequently wets bed Occasionally wets bed Walks in sleep Nightmares/terrors
b) Please explain the nature of your child’s sleep pattern:
c) Does your child have any particular fears If yes, please explain.
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2013 CAMPER HEALTH FORM:
PARENT / GUARDIAN INFORMATION:
Main Contact: Alternate Emergency Contact: Family Physician:
Name: __________________________ Name: _________________________ Name: ______________________
Relationship: ____________________ Relationship: ____________________ Phone: ______________________
Home Phone: ____________________ Home Phone: ____________________ **If there is on-going medical
supervision or care needed, a
Work Phone: _____________________ Work Phone: _____________________ referral letter from your doctor
will help the Camp Wenonah
Cell Phone: ______________________ Cell Phone: ______________________ staff facilitate that care during
your child’s stay with us**
CAMPER HEALTH INFORMATION:
1. When did your child last have a tetanus booster shot ___________________________
2. Child’s height: ___________________________ Child’s weight: ___________________________
ALLERGY INFORMATION:
3. What food allergies (if any) does your child have _______________________________________________
Please describe the allergic reaction: __________________________________________________________
Is this food allergy life-threatening Yes
No
If yes, will your child bring an EPI-PEN to Camp for this food allergy Yes No
4. My child is allergic to the following:
Insects Spiders Bees Wasps Drugs: _____________ Environmental: _____________
Please describe the allergic reaction: _____________________________________________________________
Is this allergy life-threatening Yes
No
If yes, will your child bring an EPI-PEN to Camp for this allergy Yes
No
Please describe the treatment for this allergy: ______________________________________________________
**If your child is attending a two week or one month period an extra Epi-Pen must be brought to Camp for the outtrips.**
**Please send a fanny pack to Camp with your child to carry his/her EPI-PEN**
5. If your child is bringing asthma inhalers to Camp, where should the inhalers be kept
With my child at all times (please send a fanny pack to Camp for this purpose)
In the Health Centre (inhalers will be sent with your child on all overnight out trips)
What triggers an asthma attack How frequently do asthma attacks occur
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HEALTH HISTORY:
6. Does your child have any physical limitations which may restrict his/her full participation in Camp activities
If yes, please explain (you may send a separate letter addressed to the Camp Director if necessary).
7. Does your child have any recent or current medical concerns (i.e. operation, illness, injury, etc.) If yes, please explain.
8. Does your child have any recent or current behavioural concerns (i.e. ADD, ADHD, Depression, etc.)
If yes, please explain the extent of the behavioural concern in a separate letter, and submit to the Camp Director.
9. Help us best understand your child. Does your child have any special habits, emotional, or physical needs If yes,
please explain the extent of these needs in a separate letter (for specific issues of a confidential nature, you may
address the letter to the Camp Director).
10. Has (or is) your child received psychological or group counseling, or psychiatric help Yes No
If yes, please explain in a separate letter (for specific issues of a confidential nature, you may address the letter to the Camp
Director).
11. Are there any issues of a medical nature that might arise during your child’s time at Camp (i.e. Eating Disorder,
Depression, etc.) If yes, please explain the extent of this issue in a separate letter, and submit to the Camp Director.
12. Does your child have any other health concerns and/or restrictions
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MEDICATION:
Notes:
- All medication must be sent to Camp in the original prescription container
- Ensure that all medications are brought to the Health Centre on the first day of Camp
3. Is your child currently on medication If yes, please explain.
4. Please list all medication (prescription, non-prescription, or homeopathic) that will be sent to Camp:
REGULAR MEDICATION
Medication Dosage When Given Purpose
OCCASIONAL MEDICATION
Medication Dosage Purpose
5. Will your child’s medication be altered during their time at Camp If yes, please explain.
AUTHORIZATION:
To the best of my knowledge all medical problems or conditions requiring ongoing medical supervision or care have been fully noted. I give permission
for this health information to be shared with the appropriate Camp staff and outside medical personnel as necessary. If the parent / guardian cannot be
reached, permission is hereby given to the Camp staff to take whatever steps it deems necessary to ensure the safety and health of the camper. This
also allows permission for the Camp to contact the camper’s family physician/specialist.
The courts of Ontario shall have exclusive jurisdiction over any claims, legal dispute, or cause of action during my child’s enrollment or stay at Camp
Wenonah, including, but not limited to his/her medical treatment and any relationship with a physician, nurse, or hospital. I hereby agree that if I
commence any such legal proceedings, they will be held only in the Province of Ontario, and I hereby irrevocably submit to the exclusive jurisdiction of
the courts of the Province of Ontario.
Parent/Guardian (please print): __________________________ Signature: ___________________________ Date: _______________
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CAMPER CODE OF CONDUCT
We want to avoid having more serious, but increasingly common, social problems filter in to the Camp environment. We have identified “serious”
issues as: alcohol, bullying, defiance, disorderly conduct, drugs, harassment, profanity, sexual activity, smoking, theft, vandalism, and weapons
use. In addressing these issues we hope to prevent the kinds of problems that plague schools and communities from happening at Camp. A safe
environment requires the complement of safe practices and consistent consequences. Descriptions of behaviours and potential consequences are
detailed in the Final Instructions booklet.
Mitigating factors are taken into consideration when consequencing camper/POLARIS/WCIT behaviour. Additional consequences may be added.
Any violation of the laws of the Province of Ontario results in automatic dismissal.
The Camp Administration reserves the right to withdraw any camper without warning who, in their opinion, compromises the physical or emotional
safety of any person at Camp, or who is an immediate hazard to the safety of themselves or others.
THERE ARE NO REFUNDS GIVEN FOR CAMPERS WHO ARE SENT HOME DUE TO VIOLATION OF BEHAVIOUR POLICIES
OR THE CODE OF CONDUCT.
CAMPER AGREEMENT:
Camper
I have read and discussed the policies of Camp Wenonah and the Code of Conduct with my parent(s), and I agree to abide by them and
enter into all activities with a willing and positive spirit.
Signature: ________________________________________________________
Date: ___________________________________________________________
PARENT AGREEMENT:
I have read the 2013 Camp Wenonah Summer Camp Final Instructions Handbook, and all information sent in the Final Instructions
mailing. I further understand the contents and the expectations for a safe and successful camping experience as outlined.
Parent/Guardian (please print): _______________________________________
Signature: _______________________________________________________
Date: ___________________________________________________________
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