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Sr. YOUTH RETREAT MEDICAL & REGISTRATION FORM

Please complete and hand directly to your Youth leader who will bring form
to Camp Squeah on registration day
#4 27915 Trans Canada Highway, Hope BC, V0X 1L3
(Any updates to information on this form can be noted upon campers arrival)

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Important note to parent(s) / guardian(s): please remember to sign the back of this form

PERSONAL INFORMATION - please print


Camper Name _________________________________ Boy Girl CARE CARD # _______________
Address _______________________________________________________________________________
Birth Date: d___ m___ y___ Family Doctor ________________________________ Phone _____________
In Emergency, please contact:
Parent/guardian _______________________________________________ Phone: H ________________

W _______________

If parent/guardian unavailable ____________________________________ Phone: H _______________

W _______________

ALLERGY PROFILE
The camper has:
No known allergies
known allergies (please complete the following chart)

Allergic to:
(please specify)
a) medication:

Reaction
(please specify)

Severity
(mild, medium, severe)

Treatment/medication
required

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b) foods:
c) insects:
d) environmental:
e) other:

If any allergies are severe:


a) does the camper carry an
ana kit? or epipen?

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b) does the camper know how to use an


ana kit? or epipen?

DIETARY RESTRICTIONS - other than food allergies indicated on the allergy profile.

TETANUS VACCINE
Is your campers tetanus immunization up to date? yes no
If no, please have your camper immunized prior to coming to camp
If yes, circle last year immunization was given: 2003 04 05 06 07 08 09 10 11 12 13 14

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INDICATE if the camper is subject to the following by marking the appropriate box ( )
ADD
bed wetting diabetes
headaches
migraines
stomach upset
ADHD
bronchitis
ear trouble
kidney trouble seizures
tonsillitis
asthma
colds
emotional upset menstrual cramps sleep walking
other (please specify) _______________________________

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Please give a brief description of the campers condition. What is an expected norm for him/her?
OTHER INFORMATION
Are there any other medical details, recent injuries, significant illnesses, or limitations that the medical
attendant should be aware of?

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MEDICATIONS
All medications, including all over the counter medications (e.g. Tylenol, antihistamines, lactaid, etc.) must
be given to our medical attendant at registration time. Medications must be in their original containers;
labelled with the campers name, name of drug, dosage and any other necessary information.

1. Name of Drug ___________________________ 2. Name of Drug____________________________


Dosage _________________________________
Dosage _________________________________
Reason prescribed ________________________
Reason prescribed ________________________
Administration times _______________________
Administration times _______________________
_______________________________________
_______________________________________

3. Name of Drug ___________________________ 4. Name of Drug ____________________________


Dosage ________________________________
Dosage _________________________________
Reason prescribed _______________________
Reason prescribed ________________________
Administration times ______________________
Administration times _______________________
______________________________________
_______________________________________

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FOR YOUR INFORMATION

Should your child require a physician while they are at camp, we have access to a medical clinic and a hospital in
Hope (approximately a 15 minute drive by car).

CONSENT
In the event of a minor medical occurrence, I give my approval for common "over the counter" preparations, such as
Tylenol or antihistamines, to be provided at the discretion of the Camp Medical Attendant. I also authorize the Director or
the Camp Medical Attendant to seek all necessary medical attention, in the event that the emergency contact person
cannot be reached. I further release MCBC, Camp Squeah and its personnel from all claims and damages arising from
any accidents or injuries occurring while my child is at, or in transit to or from Camp Squeah.

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Signature of Parent/Guardian________________________
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Date ___________

Furthermore, I/we hereby permit my son or daughter to attend the MCBC Senior Youth Retreat at Camp
Squeah, November 14-16, 2014. I understand that my son/ daughter will be transported to and from Camp
Squeah by private means (either by private vehicle or bus). I am aware that my son/ daughter will be
participating in various indoor and outdoor activities and games. I hereby accept the risks involved in having
my son/ daughter participate in such activities and release the leaders and/or drivers of any liability and give
the leaders permission to take any action necessary in case of emergency. I also authorize MCBC and/or
Camp Squeah to use any photographs taken of our son/daughter, while participating, in programs for
brochure and promotional materials.

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Signature of Parent/Guardian________________________

Date ___________