2020 Overnight Camper: Medical & Personal Form

Overnight Camper Medical & Personal Form

2020
The 2020 Camper Medical & Personal Form form is kept confidential.

Every camper needs a completed Medical & Personal Form to participate in any camp programs. Please fill out this form as completely as possible.

Thank you very much!
OVERNIGHT CAMPER MEDICAL FORM
Section 1 - Basic Contact Information
Camper Full Name

First Name Last Name
Camper Attending Session(s)
Date of Birth (M/D/Y) *
Camper Age as of July 1st
Gender *

Male Female
Family Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Second person to contact if parents cannot be reached in an emergency. *

First Name Last Name
Second Contact Person Phone Number *

Area Code Phone Number
Second Contact Person Email Address *
example@example.com
Second Contact Person Relationship to Camper *
Family Physician Name *

First Name Last Name
Family Physician Contact # *

Area Code Phone Number

	Select those that apply
Prefers passive activities
Athletically inclined
Enjoys competitive sports
Shy with peers
Shy with adults
Makes friends easily
Has difficulty keeping friends
Emotional
Sensitive
Easy going
Nervous
Temperamental
Happy
Aggressive
Tires Easily
Other

Section 7 - Authorization & CONDITIONS OF ENROLLMENT
Applications may be cancelled with refund (less $250.00 + HST administrative costs) for medical reasons ONLY. The financial obligations of the camp are fixed and the withdrawal of a camper does not lessen operating expenses. I understand that all funds are non-refundable after June 1st 2020 under all circumstances.

To the best of my knowledge my child is in good health and is physically able to participate in camp activities. In case of emergency, I hereby give permission to The Hollows Camp Ltd. to secure medical treatment for my child.

I understand that this information is confidential, will not be disclosed and agree that it may be stored under secure conditions by The Hollows Camp.

I hereby absolve and release The Hollows Camp Ltd., their directors, officers, employees, instructors and agents from any and all claims for damages or injuries sustained by my child or myself resulting from any activities, training, race, or competition sponsored by or carried on by The Hollows Camp Ltd.

I hereby consent that The Hollows Camp Ltd may use my camper’s photo image.

I understand that this information is confidential and agree that it may be stored under secure conditions with the camp records. I agree that this information may be shared with my child’s counsellor on an “as needs” basis.

I hereby indemnify, agree to defend, and hold The Hollows Camp Ltd. harmless from any and all loss, damage, or injury to any person or persons whosoever, or property, arising from any cause or reason whatsoever in or about The Hollows Camp Ltd. grounds or their described facilities; and further agree to waive all claims against The Hollows Camp Ltd., their employees, officers or directors on account of any loss, damage, or injury from whatever cause which may occur to it on its property in the use and occupancy of The Hollows Camp Ltd. premises; and I agree to promptly and upon demand, reimburse The Hollows Camp Ltd. for any damage done to the Camp premises or equipment, and for equipment lost or stolen by the above named camper.
Parent/Guardian Email Address *
example@example.com
Signature of Parent/Guardian *

Clear
Date *
Should be Empty:

Overnight Camper Medical & Personal Form