ZACHARY'S CAMP REGISTRATION FORM
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Email *
Name *
DOB *
MM
/
DD
/
YYYY
Healthcard Number *
Address *
Parent/Guardian *
Participant Currently Lives with *
Home Phone and/or Cell Phone *
Emergency Contact and Relationship 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 *
Doctor Name and Phone Number *
List all known Allergies and the persons 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 *
Required
Has your child ever had or currently have seizures? *
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 *
Required
Does the camper wear glasses/contact lenses *
Communication: *
Eating: *
Describe the assistance needed for eating *
Swimming: *
Please describe the participants swim skills *
The participant can: GO TO THE TOILET *
Required
The participant can: FEMININE HYGIENE
 *
Required
The participant can: GET DRESSED APPRORIATLY
 *
Required
The participant can: EATING (skills with utensils)
 *
Required
ADDITIONAL INFORMATION *
FOOD PREFERENCES *
FOOD DISLIKES *
FOOD RESTRICTIONS *
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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