Camp Chikopi Health History Form

Camp Chikopi: 373 Chikopi Road, Magnetawan, Ontario, P0A 1P0
Phone: (954) 566 8235 Summer Phone: (705) 387 3811 Email: campchikopi@aol.com

Camper Name:	Age :Date Of Birth: DD/MM/YY
Ontario Health Card No. (If Applicable): In Case Of Emergency Whom Should We Contact? Contact Information Parent/Guardian Name 1: Home Phone: Cell Phone: Work Phone:	Summer Contact Address (For Hospital Use):Parent/Guardian Name 2: Home Phone: Cell Phone: Work Phone:

The Health History Form Must Be Completed Annually.

Immunization

Is Camper Immunized - YesNo

Are Immunization`s up to date - YesNo

Does Camper Have Any Allergies:

Drugs:

Food:

Other:

Bees

Nuts

Asthma

Has Camper Ever Had:

Appendicitis

Chicken Pox

Diabetes

Emotional Disorder

Ear Infections

Heart Condition

Bed Wetting

Learning Disability

Does camper have a physical restriction at Chikopi?	YesNo
Does camper have a food restriction at Chikopi?	YesNo
Does camper have a special emotional need?	YesNo
Is there anything else we should be aware of?	YesNo

If you answered YES to any of the above, please give details:

If Camper is an Anaphylactic Please Provide a Minimum of 3 Epi Pens - Pens will be Returned at End of Session

Will camper require any treatments, injections or medications while at Chikopi? If yes, list ailment, name of drug, time and amount of dose. All medications brought to Chikopi must be in their original containers with clear directions from the Pharmacist who filled the prescription. Over the counter medications must be in their original containers with campers name clearly printed on the container.

Physician`s Name:	Address:
City:	Province/State:	Phone:

To the best of my knowledge, the above camper is in good health. If exposed to any INFECTIOUS DISEASE within FOUR (4) weeks prior to attending Chikopi, or his medical conditions change, I will notify Chikopi in writing and submit a new health form.

In case of medical emergency, I give permission to have the camp physician/Director refer my child to hospital for treatment. I also understand that the camp physician and/or directors will try to keep my family informed of any emergency plans by phoning us either at home, work or summer place as notified above.

DATE:

Enter Full Name (e-signature):

For Chikopi Office Use Only

Date:

Diagnosis:

Treatment:

Parents Notified? Yes: By Phone By Email Letter Date

Comments:

Initials