2019 Overnight Camper: Medical & Personal Form

Overnight Camper Medical & Personal Form

2019
The 2019 Camper Medical & Personal Form form is kept confidential and used only by our camp service staff (or emergency medical personnel).
Every camper needs a completed Medical & Personal Form to participate in any camp programs. Please fill out this form as completely as possible. Thank you very much!
OVERNIGHT CAMPER MEDICAL FORM
Section 1 - Basic Contact Information
Camper Name

First NameLast Name
Sessions *
Date of Birth*
Age*
Gender*

MaleFemale
Height
Weight
Note: Height and Weight information is only used to assit us in selecting an appropriate horse or pony for you child should they be riding.
Family Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Second Person to Contact if Parents cannot be reached in an emergency.*

First NameLast Name
Second Contact Person Phone *

Area CodePhone Number
Second Contact Person Relationship to Camper *
Second Contact Person Full Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Family Physician Name

First NameLast Name
Family Physician Contact #

Area CodePhone Number

Section 2 - Insurance Information
Ontario Health Card Number*
Is the camper covered by other medical/hospital insurance?*

YesNo
Other Medical Insurance *
Section 3 - Medications
Will camper be taking medications while at The Hollows Camp? (This includes prescriptions, over-the-counter, vitamins, inhalers, etc.)*

YesNo
Please list all medications (prescription and non-prescription). Include the medication name, prescribing physician, dosages and dosing instructions. When you check in at camp please provide all medications in their original packaging that identifies the prescribing doctor (if prescriptions drug), the name of the medication, the dosage, and the frequency of administration.*

	Select those that apply
Prefers passive activities
Athletically inclined
Enjoys competitive sports
Shy with peers
Shy with adults
Makes friends easily
Has difficulty keeping friends
Emotional
Sensitive
Easy going
Nervous
Temperamental
Happy
Aggressive
Tires Easily
Other

Overnight Camper Medical & Personal Form