ZACHARY'S CAMP REGISTRATION FORM 2024

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Email *

NAME *

DOB *

YYYY

HEALTHCARD NUMBER *

ADDRESS *

PARENT/GUARDIAN *

PARTICIPANT CURRENTLY LIVES WITH *

HOME PHONE AND/OR CELL PHONE *

EMERGENCY CONTACT AND RELATION SHIP TO PARTICIPANT *

In case of medical emergency, you give permission to the physician selected by Zachary's Camp staff to secure proper treatment to your child, through the Emergency department of the nearest hospital. These services will be obtained for the child and charged to the parents/caregiver or to families Ontario Health Plan. All efforts will continue to be made to contact parents/caregiver/emergency contacts at the numbers listed above
*

YES I AGREE

NO-I DECLINE

DOCTOR NAME AND PHONE NUMBER *

LIST ALL NOWN ALLERGIES AND THE PARTICIPANTS REACTION (MEDICAL,FOOD,ENVIROMENTAL) *

Medication: All medication is required to be in the ORIGINAL container with dosage and doctors name clearly labeled. Medication administration form must accompany medication. All medication has to be given to Antje van Dipten
*

YES-PLEASE ADMINISTER MEDICATION

NO-MEDICATION REQUIERED

Required

Has your child ever had or currently have seizures?
*

Yes

If YES, please describe care, concerns and actions required. Please provide a protocol when to call an ambulance. Zachary's Camp Policy is to call EMS after 1 Minutes duration of Seizure
*

Does your camper wear hearing aids
*

YES

Does the camper wear glasses/contact lenses
*

Yes

Communication:
*

Eating:
*

needs assistance

independent

Describe the assistance needed for eating
*

Swimming:
*

Swimming:

swimmer -touch ground at all times

swim vest required

Please describe the participants swim skills
*

The participant can: GO TO THE TOILET
*

independently

needs reminders

verbal prompt

needs assistance

The participant can: FEMININE HYGIENE
*

independently

needs reminders

verbal prompts

needs assistance

The participant can: GET DRESSED APPRORIATLY
*

independently

needs reminders

verbal prompts

needs assistance

The participant can: EATING (skills with utensils)
*

independently

needs reminders

verbal prompts

needs assistance

ADDITIONAL INFORMATION
*

FOOD PREFERENCES
*

FOOD DISLIKES
*

FOOD RESTRICTIONS (NO SUGAR,NO RED FOOD COLORING
*

FOOD ALLERGIES
*

IS THERE ANY ADDITIONAL INFORMATION THAT WE SHOULD BE AWARE OF RELEVANT TO YOUR PARTICIPANTS PARTICIPATION IN ZACHARY'S CAMP?
*

By writing your name and date and submitting this form we consider the document signed
*

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