CAMPER’S NAME ____________________________________________________________

Please indicate if the camper has an allergy/reaction to any of the following:

Drugs/Medication:_____________________________________ ____________________________

Insect Sting (e.g. bee/wasp sting)________________________________________________________

Hayfever, Animals:__________________________________________________________________

Food/ Peanuts etc:”________________________________________________________________

Other: _______________________________________________ ____________________________________

Does your camper carry an or any other allergy medication? Yes No

Please elaborate on the severity of the reaction and best methods of treatment to any of the above (attach additional page if necessary ) ___________________________________________________________________________________________________________________________________________________________________________

Does your camper have any restrictions/considerations in relation to the following”:

Diet:_________________________________________________ _______________________________________

Physical Activity:_______________________________________________________________________________

Other:________________________________________________________________________________________

Identify any other information we require concerning your camper:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I, the undersigned parent or guardian, have provided a nd correct health history and permit my child to participate in the full range of camp activity, except as noted in the information provided.

To the best of my knowledge the above named camper is in good health and has not been exposed to any infectious disease. He or she is physically able to participate in all activities except those indicated under restrictions above. In the case of surgical emergency where I am not immediately available for consultation, I herby give permission to emergency personnel to hospitalize, to secure treatment for and to administer emergency procedures to the camper. Furthermore, I give permission to all Camp Staff to administer first aid treatment to the camper including standard CPR and the use of emergency dical services, within the Township of Uxbridge.

______________________________________________________ ___________________________________ signature date______________________________________________________ ___________________________________

Personal information is collected under the authority of Freedom of Information Act and Protection of Privacy Act (R.S.O. 1990, c F.39(2) and will be used for Dream Feather Volleyball Camp and related administration or consistent purposes. If you have any questions about eh iuse, collection and disclosure of personal information by the camp, please contact Larry Griffiths (Director)

Allergies and Reactions:

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Restrictions: