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ParticipantsFirstname: MICHAEL
ParticipantsLastname: MARK
Relationshiptocamper: NANNY
NO
Arethereanyexistingcustodyissues?__________________________________________________________
Pleaseprovidethenamesofanyonewhomaybesigningthecamperoutattheendoftheday:
ProvincialHealthCardNo.:(IffromoutsideCanadaMedicalPlan#)
PROKOPIAK (613) 836-5083
Doctorsname:Doctorsphonenumber:
MedicalInformation
Isthecampercurrentlyunderthecareofaphysician?YesNo
Ifyes,pleaseprovidedetails:
Doesthecamperhaveanyallergies?YesNo
Ifyes,pleaseprovidedetails:
Hasthecamperexperiencedsymptomsofacommunicablediseaseinthepast3weeks?YesNo
Ifyes,pleaseprovidedetails:
Hasthecamperreceivedpsychological,groupcounselling,orpsychiatrichelp?YesNo
Ifyes,pleaseprovidedetails:
HasthecamperreceivedallimmunizationsrecommendedbytheOntarioMinistryofHealth?YesNo
Ifno,pleaseprovidedetails:
MyMedicalRecord
Icertifythatallinformationprovidedonthisformisaccurateandcomplete(attachadditionalsheetsif
required).
Parent/guardiansignature:
Date:CampDirectorsignature: