LDC Health Form
Please submit the form prior to arriving on registration day so we can have time for review and follow up.  
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Name *
Health Card Number *
Date of Birth *
MM
/
DD
/
YYYY
Sex/Gender (& other notes regarding gender) *
Address *
Parent/Guardian Primary Phone number (& name)
Parent/Guardian Secondary Phone number (& name)
Alternative Emergency Contact Phone number ( & name & relationship)
Physician's name & phone # *
Health Conditions and Notes
Please note: in most cases,  medication will kept & administered by the camper themselves.  Please indicate and/or discuss if other arrangements should be made.  
Please indicate any of the following conditions which apply to the camper either at present or in the past: diabetes, epilepsy, appendicitis, asthma, frequent headaches, heart condition, sleep walking, spells of fainting, strep throat, bronchitis.
Please indicate any other physical health conditions or concerns we should be made aware of. Is there any health condition that would prevent this camper from full participation in the Camp program?
Please indicate any mental health concerns.  Please include as much helpful information here as possible;  including coping strategies, medication, and level of support needed/expected.  
Please list any treatments, injections or medications, frequency of administration and reason for their use, for the camp's health care representative/nurse.
Please give any information that you feel may be helpful to the camp nurse/staff in case of emergency or helpful to the Directors for supervision and support.  
Allergies
Please check if camper has allergies to any of the following:
Please list the name of food, animal, insect, drugs and/or other allergies, describing the reaction experienced, previous treatment given, date of treatment and the attending physician. *
Does the camper carry an EPI·PEN? *
Date of last tetanus shot? *
PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY AND INDICATE YOUR APPROVAL BY CHECKING THE BOX NEXT TO IT
1. I give permission for my child to participate in the LDC program and acknowledge that there are risks involved in such a program. I will not hold the LDC staff, United Church Camp Staffs, UCOM,  or the United Church legally or financially responsible for any damage to person or property. The United Church does not provide any accidental death, disability, dismemberment or medical expense insurance on behalf of camp participants. *
Required
2. To the best of my knowledge this camper is in good physical and mental health. *
Required
3. Should this camper come in contact with an infectious disease prior to camp, I understand that the camp must be notified. *
Required
.4. In the case of a surgical emergency where I/we (parents or guardian) are not available for consultation,I give permission to the physician selected by the Camp Director or the Camp Nurse to hospitalize, secured proper treatment and order injections, anesthesia etc... *
Required
5. I also give permission to administer any prescription or non-prescription drugs (Tylenol, Advil,Benedril, etc... as ordered by age except aspirin) deemed necessary by the Camp Nurse or First Aid certified staff person. *
Required
Please type your name & current date below as an indicator of your agreement and signature *
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