Consent Form and Liability Waiver - Diocese of London

y hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers,contact:Name: & Relationship:______________________________________________________________________Phone: _____________________________ Family Doctor: ________________Phone:__________________Provincial Health Number: __________________________________ Date:___________________________Signature:_________________________________ Date: ________________________Other Medical Treatment: In the event it comes to the attention of the parish, its officers, directors and agentsand the Diocese of London, chaperones, or representatives associated with the activity, that my child becomesill with symptoms such as headache, vomiting, sore throat, fever, diarrhea, I want to be called collect (withphone charges revered to myself).Signature:_________________________________ Date: ________________________Medications: My child is taking medication at present. My child will bring all such medications necessary,and such medications will be well-labeled. Names of medications and concise directions for seeing that thechild takes such medications, including dosage and frequency of dosage, are as follows:________________________________________________________________________________________Signature:_________________________________ Date: ________________________No medications of any type, whether prescription or non-prescription, may be administered to my child unlessthe situation is life-threatening and emergency treatment is required.Signature:_________________________________ Date: ________________________I hereby grant permission for non-prescription medication (i.e. non-aspirin products such as acetaminophen oribuprofen, throat lozenges, cough syrup) to be given to my child, if deemed appropriate.Signature:_________________________________ Date: ________________________Specific Medical Information: The Diocese of London and parish will take reasonable care to see that thefollowing information will be held in confidence.Allergic reactions, medications, foods, plants, insects, etc):_________________________________________Immunizations: date of last tetanus/diphtheria immunization:________________________________________Does child have a medically prescribed diet?_____________________________________________________Any physical limitations?_____________________________________________________________Has your child recently been exposed to contagious disease or conditions, such as mumps, measles, chickenpox etc? ________________________________________________________________________________You should be aware of these special medical conditions of my child:________________________________________________________________________________________________________________________Administrative Matters: The Diocese of London would like permission to use photos of camp participants inour publications and web site. It is understood that the names of campers will be withheld.☐ I give permission for photographs of the person named above to be used in Diocese of Londonpublications and web site.Signature:__________________________________Date________________________________