March Break - Health Info - Camp Eden Woods

Camper Information

* Indicates required field

Name *

First

Last

Date of Birth *

Mother's Name *

Mother's Phone # *

Camper Phone # *

Mother's Email *

Father's Name *

Father's Phone # *

Father's Email *

Parents' Marital Status *

Visitation Rights & Custody Information (if applicable): *

If there is one parent who is the main point of contact? *

Emergency Contact

Name *

Relation: *

Emergency Contact Phone Number *

Name *

Relation *

Emergency Contact Phone Number *

Are there any activities to be restricted? *

Please list all of your child's allergies (for severe alergies, please fill out a Severe Allergy Form) *

Please list any chronic or recurring illnesses or medical conditions *

Please list all medication your child is current taking (and send us instructions) *

Please list your child's dietary restrictions or sensitivities *

Is there anything you would like us to know about your child's sleeping habits or special rituals / traditions at night? *

Other Important Information about your child? *

OHIP # *

Health / Travel Insurance

Indicate carrier - name of insurance company *

Policy # *

Carrier Address *

Suscriber *

Conditions:

Camp Eden Camps will not accept responsibility for any money lost or stolen. Similarly, Camp Eden Camps will not be held responsible for any damage, loss or that of any campers’ personal belongings. Campers are encouraged not to bring any valuables.
Although Camp Eden Camps strives to maintain originally planned activities and schedules, each program is subject to change due to weather and/or other special circumstances.
Medication carried by campers will not be administered if a pharmacist or a physician does not properly label contents and instructions.
It is the responsibility of the parent/guardian to inform Camp Eden Camps if there are any changes in the child’s medical condition after this form has been submitted.
If the camper has a presently life-threatening allergy or food sensitivity, we ask that the parent or guardian contact the office prior to completing and returning this form so that an allergy description form can be mailed to you. Please note that while in Spain, our food choices will be nut sensitive, but due to our lack of full control we cannot guarantee being completely free of peanuts or other foods that may cause allergic reactions.
Information collected on this form is for the use of the medical and programming decisions of Camp Eden Camps. We will not share personal information with any other organization, except for medical professionals, without the prior consent of the parents/guardians. For questions about our privacy policy, please contact our privacy coordinator, Sharon Gluzberg.

Personal Declaration

This personal and health history is correct so far as I know, and the person herein described has permission to engage in all CEW Road Trip activities except as noted. Authorization for treatment: I hereby give permission to the medical personnel selected by the camp director to order x-rays, routine tests, treatment, to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for the child named above. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director to secure and administer treatment, including hospitalization, for the person named above. I agree to be responsible for any expenses incurred by my child or by Camp Eden Woods on behalf of my child

Submit

March Break Trip

Camper Information

Telephone

Email