Hockey Opportunity Camp

	2010 HEALTH HISTORY FORM

	Box 448, Sundridge, ON P0A 1Z0 Phone 705-386-7702 Fax 705-386-0179

Please complete and submit form prior to May 1, 2010. It is mandatory that we receive all completed and up to date health history forms (each year) prior to Check In Day.

Camper ID#

Do Not Know ID#

Check every camp week attending *

1 2 3 4 5 6 7 8

Last Name

First Name

Height (ft)

Weight (lbs)

Gender *

M F

Age at Camp

Date of Birth (M/D/YYYY) *

Will your child celebrate His/Her birthday while at Camp?

Yes

Mailing Address

City

Prov./State

Postal/Zip Code

Home Phone Number

ONTARIO HEALTH CARD #
Campers from outside of Ontario should arrange for "out of province" health insurance prior to arriving in Ontario. If a camper does not hold a valid Ontario Health Card number, any medical visits/charges will be billed back to camper and charges will need to be covered by parent/guardian credit card.

Date of Last Doctor's Exam (MM/YYYY)

Approx. Date of Last Tetanus Shot (MM/YYYY)
Must be current, within 10 years

Recent Vaccinations (i.e H1N1, Flu Shot) (within 12 months)

MEDICATIONS: All medications (except inhalers) must be turned in and kept in the Health Centre and dispensed by the Camp Health Care Staff. Medications must come in the original container and include the camper's name & directions for use. Parents are responsible for checking the expiry dates.

1. Please list any medications you are sending with your child to camp:

Medication

Purpose

Medication

Purpose

2. List any medications you DO NOT want your child to receive (ASA is not given):

3. Please indicate any prescribed medication that you or your Doctor have decided to discontinue during the camp period:

ALLERGIES: List any known allergies (and level of severity) that your child has (i.e. Drugs, Food, Insect Bites, Hay Fever):

Will your child be bringing an Epi Pen(s)?		If yes, does your child know how to use it?
Campers bringing their own Epi Pen(s) must also bring a fanny pack to carry it in.

OTHER: Are there any other personal or health issues that the Camp Health Care Staff should be aware of or any medical conditions that would affect his/her participation in any camp activity? Please check any of the following items and detail below.

Asthma	Nightmares	Homesickness	Sleepwalking	Headaches
Hearing Difficulties	Eating Disorders	Diabetes	Heart Conditions	Skin Conditions
Behavioural Concerns	Bedwetting	Seizures	ADD/ADHD	Head Lice
Previous Injury	Vision	Mobility	Other

Is there any information on the camper's family structure that would be important for the Camp Health Care Staff or Camp Directors to be aware of? (Parents separated, divorced, custody issues, loss of family member, etc.)

Terms of Enrollment

• If my child shows symptoms or is in contact with anyone showing such symptoms (up to 72 hours prior to the arrival at camp) of the following: 1/ Gastrointestinal illness including, but not limited to vomitting, chills, abdominal cramps and diarrhea or 2/ Influenza Like
Illness (ILI) including, but not limited to, fever with cough and one or more of the following symptoms; sore throat, muscle aches, joint pain or weakness or 3/ Any other health concern that poses a threat to the health and well being of the camp community, we declare that the camp will be contacted immediately.We understand that such symptoms will delay arrival to camp as determined by the Camp Director.

• Campers are not permitted to possess any cigarettes, alcohol or illegal drugs. Campers found with such items or campers exhibiting behaviour that is detrimental to other campers and/or the camp community will be asked to leave before his/her session ends. No refund will be considered if a camper is required to leave for one of these reasons.

• Campers defacing property, or purposely damaging property of HOC or that of other campers, will be held responsible for the cost associated with repair or replacement.

Medical Waiver

• Although a doctor's examination is not required, HOC requires that all medical problems or conditions requiring on-going medical supervision or care to be fully disclosed. In addition, all campers must be covered by Ontario Health or equivalent health insurance. I give permission for this health information to be shared with the appropriate camp staff and outside medical personnel as required (while understanding and following the camp privacy policy). Permission is also given to the camp staff to take whatever steps deemed necessary to ensure the safety and health of the camper. This includes providing common, non-prescription medications such as Acetaminophen, Ibuprofen, Gravol, Kaopectate, cough syrup, etc. In the case of a medical/surgical emergency and parents/guardian are not immediately available for consultation, I hereby give permission to the physician selected by the Camp Director/Health Care Staff to hospitalize and secure proper treatment for my child (as named on the medical form).

• The sport of hockey and other camp activities involve known and unknown risks, which could result in physical injury. All hockey players must wear full CAHA (or equivalent) approved equipment. Campers must abide by all prescribed safety measures for all camp activities. Eagle Crest Resorts Ltd. will not be responsible for any participant's fitness,faulty camper equipment or any injury that may occur while participating in any camp activity. I hereby waive,release/absolve and agree to indemnify and save harmless Eagle Crest Resorts Ltd. and its directors, officers,employees and agents of and from any and all liability arising therefrom, except such as shall arise solely as a consequence of its or their gross negligence or gross default.

• Although the camp and/or caterer make every effort to accommodate all campers with food allergies, the camp or its suppliers cannot be held responsible in the event of an allergic reaction. Depending on the allergy(ies), it maybe necessary for the Camp Director to determine if camp registration is feasible. In addition, it may be necessary for parents to provide specialty foods not available through our normal food distributor.

• I acknowledge that camp takes place in Ontario and that Ontario Courts shall have jurisdiction over any claim, legal dispute or cause of action arising during camp, alleged breach of contract or alleged negligence or other claim that leads to a legal proceeding against Eagle Crest Resorts Ltd. I agree that the resolution of all disputes arising with camp shall be governed and construed in accordance with the laws of Ontario and exclusive jurisdiction of the Province of Ontario courts.


Parent/Guardian's Name		Date (mm/dd/yyyy)
Email Address

I hereby certify that all information completed on this form is accurate and up to date and I will contact the camp in writing if there are any changes. I have also read and accept the Terms of Enrollment and Medical Waiver.

Note: All yellow items or items with a * beside them must be filled out completely for submission