Funvilla Summer Camp

CAMPER HEALTH FORM
Camper's Last Name*
Camper's First Name*
Camper's Middle name Initial
How often will the camper be attending camp?*

1 Day a week (Casual Camper)3 Days a week (Consistent Camper)5 Days a week ( Champion Camper)
Week of camping*
Health Card Number
Date of birth*

MonthDayYear
Home address
Contact Information
Parent/Guardian*
Relationship to camper*
Home Phone*
Work Phone
Home address
Email address*
Other Emergency Contact*
Relationship to camper*
Home Phone*
Work Phone
Family Doctor
Phone
Additional Information
Does your child have special needs?*

YesNo
Does your child have special needs?*

YesNo
Please describe:*
Health Concerns (diet/allergies/chronic conditions or special considerations we should be aware of as we prepare for your camper)*

Please email us at kw@funvilla.ca to discuss this further, please do not pay the deposit until then, thank you

If your camper has had any other operations or serious injuries please explain
Please note: To care for your child to the best of our ability, please describe any other physical, emotional or behavioral problems
Has your child been exposed to or suffered from any infectious disease during the three weeks prior to the first day of camp? For example: Measles, Chicken Pox, Mumps, Tuberculosis, Whooping Cough, H1N1, Mononucleosis, etc. If yes, please call the Camp Director before coming to camp.*

YesNo
Date of last immunizations

MonthDayYear
Does your camper receive any medication? (if yes, please explain below)*

YesNo
1. Illness/Condition, Medication, Dosage, Time of day given*
2. Illness/Condition, Medication, Dosage, Time of day given
Please Note:

Head Lice: Parents/guardians of children identified with head lice or nits will be notified by the Camp Director and will be required to seek treatment for the child. It is recommended that other members of the householdbe checked as well. The parent/guardian is required to pick up the child immediately and keep them at home until the problem is cleared. Once the problem is cleared the child is welcome back.

All information in this form is confidential.
Signature of Parent/Guardian*

Clear
Date*

MonthDayYear

Will you be opting out of the lunch, snack, drink option Provided by Funvilla?*

Yes (If you chose to opt out please ensure you are providing your child with a lunch box and at least 2 snacks every day)No (Lunch and snacks will be provided by Funvilla)

Parents that might Pick up/Drop off Camper

(Please note, any parents picking up will have to bring a piece of photo ID with them for confirmation, the name must match one of the names entered below)
Full Legal Name*
Relationship to Child*
Full Legal Name
Relationship to Child
Full Legal Name
Relationship to Child
Full Legal Name
Relationship to Child
Full Legal Name
Relationship to Child

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Contact Information