EmailMeForm
HOTM HEALTH & CONSENT FORM 2019
Camper Name
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First
Last
HEALTH CARD NUMBER and 1 or 2 digit Version Code
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A photocopy of the health card, FRONT and BACK, is required for overnight campers.
Please check the week(s) the camper is registering for. Please submit the registration form prior to the health form.
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HOTM Overnight Camp, July 7 - 13
HOTM Sports Day Camp, July 8 - 12
HOTM Arts Day Camp, July 15 - 19
HOTM 'The Quest', July 22 - 26
Camper Birthday
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MM
/
DD
/
YYYY
Is camper up to date with vaccinations as per Ontario Ministry of Health and Long-Term Care guidelines? ?
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Yes
No
If the answer is “NO”, does your child have an exemption as determined by the Ontario Ministry of Health?
Yes
No
Does the camper have any Anaphylactic (life-threatening) allergies?
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Yes
No
Will they be bringing an epi pen?
Yes
No
Are there any allergies? If yes, please list commenting if necessary.
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If yes to allergies please explain:
Is there any restriction to diet?
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Yes
No
Is there any restriction to physical activity?
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Yes
No
MEDICATIONS
Does the camper currently take any medication including non prescriptions?
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Yes
No
Will the camper be taking medication while at camp?
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Yes
No
All meds, non prescription, vitamins and supplements must be in the original container or pharmacy issued blister pack. All must be turned into the nurse upon arrival at camp. Please send enough to last the entire camp week.
MEDICATIONS COMING TO CAMP WITH CAMPER
Medication 1: Name of medicine
Reason for taking and for how long?
Times it is taken, the dose and how is it taken.
Medication 2: Name of medicine
Reason for taking and for how long?
Times it is taken, the dose and how is it taken.
Medication 3: Name of medicine
Reason for taking and for how long?
Times it is taken, the dose and how is it taken.
IF THERE HAVE BEEN ANY RECENT ILLNESSES PLEASE LIST
IS THIS YOUR CAMPERS FIRST CAMP EXPERIENCE?
*
Yes
No
INFORMED PARENT CONSENT FOR PARTICIPATION AT HOTM
Address Permission:
I give my consent for my child’s address to be given to the huddle leader so
that they may contact my child after camp with a birthday card/Christmas card/etc.
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Yes
No
Stayner Churches offering youth programs:
Our Stayner area churches offer excellent programming in the fall through spring season. They would like to send a reminder notice to your email with info about the start-up of clubs and programs for youth.
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Yes
No
1. The Directors have the right to dismiss any camper who is in his/her opinion a hazard to the safety or rights of others or who appears to have rejected the reasonable expectations of the camp.
2. There will be no reduction or refund of camp fees for campers arriving late, leaving early, or who are expelled due to disciplinary action.
3. The parent/guardian agrees to reimburse the camp for any property damage caused by the camper.
4. I confirm that all information in the health form is accurate. All over the counter meds and RX will be given to the camp nurse.
Release of Liability:
I give my consent for this camper to participate in the activities of camp. While every precaution is taken for their safety and good health, some activities do carry with them the inherent risk of personal injury beyond the risks associated with traditional recreational activities. I/We understand these risks and accept them. I agree that by allowing my child to participate, the potential for injury is present.
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Yes, I agree
No
Medical Release:
I authorize camp personnel to handle medical emergencies with my
camper during their stay at camp. Every reasonable effort will be made to first contact the parent/guardian listed and permission is hereby given to the physician to provide proper treatment.
The parent/guardian is responsible for any extra expense that may result. In case of injury requiring medical care, the first call is to the parent/guardian. HOTM Staff will not transport campers to medical centers/hospitals.
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Yes, I agree
No
Permission to Teach:
I understand that HOTM is a Christian faith-based day camp and that Biblical values and doctrines will be taught.
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Yes, I agree
No
Media Release:
I give permission for my child to be photographed and/or videotaped for promotional reasons. If you DO NOT permit photographs of your child please attach a picture to this application for our files and picture editor to note.
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Yes, I agree
No
Waiver:
I agree to indemnify and hold blameless Evergreen Christian Ministries, its staff, its directors and board and the medical personnel representing the camp from and against any loss, damage, or injury suffered by the camper as a result of being a participant in the normal activities of Heroes on the Move Camp. This consent is valid only for the time period July 7 through 26, 2019.
*
Yes, I agree
No
Conditions of Acceptance at Camp:
To the best of my knowledge, the Health Form is correct and the child herein described has permission to engage in all camp activities, except as noted.
I agree to notify the Camp Office if there is any change in the health of the child herein described between the time of completion of this Health Information Form and their (daily) arrival at Camp.
*
Yes
No
I confirm that I am the primary contact for this application. By checking the yes box, this is my agreement with HOTM and ECM.
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Yes, I authorize that I am the contact person responsible for this camper's information and application.
NOTICE TO PARENTS OF 'THE QUEST' CAMPERS: On Monday July 22 at drop off time, parents will be given a schedule of the week with the destination of the day listed for each day of the week. You will be required to sign off on that indicating that you know your camper is travelling on a bus and where they are headed with departure and return times.
My camper is a Quest camper and I will be present on July 22 to sign off on the liability waiver. If I cannot be present I will contact the registrar prior to complete the form. Contact registration at hotm@ecmcamps.ca
Signature
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Clear
Name
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First
Last
Email of Parent/Guardian
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Confirm Email
Signature
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Clear
