CAMP MEDICAL FORM

This form must be completed in full. If special medical treatment is required, please send an e-mail explaining special medical treatment required that can be given to the Camp Nurse or monitor.

Last Name: First Name:

Address: Apt. No:

City: Prov: Postal Code:

Telephone:

Date of Birth:D/M/Y

Age: M/F:

Medicare No:

Expiry Date:

Family Doctor:

Doctor's Phone Number:

Has camper had a tetnus shot in last 5 yrs: Yes No

Allergies:

Food Allergies:

In Case of Emergency, Please Contact:

Name:

Phone Number:

Work Number:

Other Number:

Second Contact:

Phone Number:

If on vacation while child is at camp, where can you be reached:

Camp Applied for:

Junior Co-ed - (Ages 8–13) – July 5 - 11

Annual General Meeting – July 11

Day Camp (Ages 6+) – August 24– 28

50+ Camp – September 6– 11

Second camp choice:

Choice of cabin mate: