Health Information Form

– Step 1 of 8

Thank you for completing you Moorelands Camp Health History Form online.

Please note, you will have to complete a separate form for each child who will be attending Moorelands Camp.

Before completing the form, ensure you have the following documents ready to upload either as pdfs/images/scans:

1. A copy of your child’s health card.

2. If your child currently has or has had Asthma, an electronic copy of the Action Plan and/or Approval to Attend must be uploaded. Please click here to download the Approval to Attend document

Also have on hand: Your Child’s immunization record

Please note that forms cannot be saved and edited later so please make sure that you have all documentation on hand.

This form is due 1 month before the start of your child’s camp session..
Thank you!

CAMPER INFORMATION

Camper's Name *

First

Last

Health Card Number *

Version Code Initials *

Expiry Date (mm/dd/yyyy) *

Please upload a copy of the camper's health card *

Family Doctor's Name *

Family Doctor's Phone Number *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Sex *

Male
Female

Birthdate (mm/dd/yyyy) *

Height *

Weight *

CONTACT INFORMATION

While this camper is at camp the contacts listed below must be available for contact. If contact numbers change, notify the camp

Parent(s)/Step-Parent(s)/Guardian(s) *

First

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Home Phone

Business Phone

Cell Phone

Emergency Contact(s) Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Home Phone

Business Phone

Cell Phone

CAMPER IMMUNIZATION RECORD

Please indicate date last given (mm/dd/yyyy):

Diptheria *

Polio *

MMR *

Tetanus *

Pertussis (Whooping Cough) *

Hepatitis B

Varifax (Chicken Pox)

Flu Vaccine

General Health Questions

Does your child have any of the following allergies? *

Food Allergies
Medication Allergies
Other Allergies (bee stings, etc)
None

Please list all food allergies: *

Please list all allergies to medication: *

Please list all other allergies: *

Does this camper carry an Epipen/Twinjet? *

Which allergy(s) is the Epipen/Twinjet for? *

Campers requiring an Epipen/Twinjet provide their own hip pack and carry their Epipen/Twinjet at all times.

Does this camper have any dietary restrictions camp should be aware of (ie vegetarian, lactose intolerant, etc)? *

Please list all dietary restrictions below *

Does this camper have a history of Asthma or shortness of breath? *

Has this camper ever had difficulty breathing? *

Does exercise make it worse? *

Is this camper on medication for Asthma? *

Does this child use inhalers? *

Has this camper ever been on medication to help them breath? *

Has this camper ever had to visit the emergency department because they had difficulty breathing? *

Does this child currently have Asthma? *

Please upload a copy of their Asthma Action Plan (this is required for attendance) *

Is this child currently under the care of a physician for long or short term conditions? *

Please explain: *

Does this camper have ADD/ADHD? *

Are they currently receiving ADD/ADHD medication? *

If YES, please make sure to list this medication in the medication section

Is your child experiencing any emotional, mental health, or behavioural challenges? *

Please explain: *

Does this camper have any physical limitation and/or activity restrictions (cannot take part in an activity)? *

Please explain *

Does your child currently have any of the following (please check ALL that apply): *

Athlete’s Foot
Headaches
Fainting Spells
Tonsillitis
Frequent Colds
Sleep Walking
Chickenpox
Cystitis
Heart Condition
Nightmares
Mumps
Skin Conditions
Bed Wetting
Hay Fever
Red Measles
Toothaches
Epilepsy
Sinusitis
German Measles
Whooping Cough
Motion Sickness
Ear Trouble
Rheumatic Fever
Mononucleosis
Depression
Stomach Aches
Scarlet Fever
Eating Disorder
Anxiety Disorder
Concussion
Other
None of the above

Please specify other: *

Has your child had any of the following (please check ALL that apply): *

Athlete’s Foot
Headaches
Fainting Spells
Tonsillitis
Frequent Colds
Sleep Walking
Chickenpox
Cystitis
Heart Condition
Nightmares
Mumps
Skin Conditions
Bed Wetting
Hay Fever
Red Measles
Toothaches
Epilepsy
Sinusitis
German Measles
Whooping Cough
Motion Sickness
Ear Trouble
Rheumatic Fever
Mononucleosis
Depression
Stomach Aches
Scarlet Fever
Eating Disorder
Anxiety Disorder
Concussion
Other
None of the above

Please specify other: *

Has your child had any operations? *

Please list all operations your child has had *

Does the camper use any of the following (check ALL that apply)? *

Eye Glasses
Contact Lenses
Dental Appliance
Prescribed Earplugs
None of the above

For Female Campers: Has menstruation started? *

Has it been explained? *

MEDICATION

Please note: Moorelands requires campers who take medication during the school year to continue their routine while at camp. All medication coming to camp must be in the original container with current, readable, English labels. Blister packs are to contain only one type of medication.

List all medication the camper is currently taking. Use one line per medication and list the condition it is for and the dosage. *

If your child is currently not taking any medication, please type “none” and proceed to the next page.

Medical Authorization

To the best of my knowledge, the above named camper is in good health. Should the camper be in contact with an infectious disease or should there be changes to the above information before departure for camp I understand that I must notify the registrar at 416-466-9987 ext 300.

In case of emergency, I hereby authorize the Health Care Staff, Camp Director, or designate to contact the emergency contact and/or the physician as required. In case of emergency, I hereby authorize the Health Care Staff, Camp Director or designate to secure medical advice and services (including hospitalization, anesthesia, surgery and dental care) as may be deemed necessary, if your attempt to reach me is unsuccessful. I understand that Moorelands Camp is water-access only and there is no doctor on site. If urgent medical help is required it will take approximately forty-five minutes to access EMS (Emergency Medical Services) or send a camper to the hospital.

By typing your name here you are consenting to the above statements and that all information submitted is accurate to the best of your knowledge. *

First

Last

Date *

Please check that all information is correct and click the button below to submit the form. Once the form is submitted you will need to call the office to make any changes.