Registration form.qxd

CAMP MUSKOKA
CAMP MUSKOKA
Rules & Regulations
OU T D O O R E D U C AT I O N C E N T R E
1745 FRASERBURG ROAD • RR 5 • BRACEBRIDGE • ONTARIO • P1L 1X3
Students must show respect for each other, the staff, their surroundings, theproperty and most importantly themselves.
3. Students must obey all staff’s directions.
R E G I S T R AT I O N F O R M
4. All medications* shall be deposited with your child’s teacher so that they may be locked in ONE STUDENT PER FORM
the camp medical cabinet dispensed to your child as prescribed.
Student’s Name:____________________________________________________________________ Male * Epipens and puffers can be carried by the student in a waist pouch (please see Student Health Form).
5. Drugs, cigarettes, alcohol, matches, lighters and knives are prohibited at camp. Any student Date of Birth: __
_ Age at Camp:_________ Height:_____________ Weight: ___________
found in possession of such objects will be sent home without a refund.
Camp Muskoka has a ZERO TOLERANCE policy. Any student causing or
Address: ___________________________________________________________________________________________________ intending to cause harm to any other student, animal or staff member will be senthome without refund.
City / Town:______________________________________________________ Postal Code:__________________________ ( )___________________ e-mail:_________________________________________ Ontario Health Card Number.:___________________________________________________________________________ Conditions of Enrollment:
Other Ins.-Name: _______________________________________ Number:_______________________________________ 1. The Camp Director reserves the right to dismiss a student who in his opinion is a hazard to the safety of others, or who appears to have rejected
the reasonable controls of the camp. The parent/guardian certifies that the above named student is normal in condition and habits and responsive to
necessary discipline. Failure to disclose problems at time of application may result in dismissal. 2. The parents/guardians submitting this application
Name of school :______________________________________________________________________ Grade : __________ are those having legal custody over the child. 3. I, the parent or guardian of the above named participant release Camp Muskoka, its directors,
corporation members, staff and agents, the school and/or board of education which has organized the excursion, its directors, staff and agents from
any loss, personal injury, accident, misfortune or damage to the above named or his/her property with the understanding that reasonable precautions
1st Parent/Guardian Name: _______________________________________________________________________________ shall be taken to ensure the health and safety of the above named student. Each student must be covered by Ontario Health Insurance or equivalent
insurance. 4. The signature of the parent/guardian on this application gives the Camp Director the right to arrange for any special services or other
( ) ________________________________ Work Tel: __________ requirements necessary for the best interest of the student and shall give the Camp Director the right to approve and obtain medical attentionnecessary for the student’s welfare and good health including ordering injection, anaesthesia or surgery. In such a situation the camp will attempt to notify the parents as soon as possible. The parents/guardians are responsible for any additional expenses that may result from such services. 5. We
Cell Tel: ____________________________________________ Other Tel: __________________________________________ agree to permit the reasonable use of photographs and videos or other pictures of the above named student in promoting the camp or camp activities
and programs. 6. Refund policy: No refund will be made for dismissals due to disciplinary action, late arrivals or early departures. Withdrawal
2nd Parent/Guardian Name: ______________________________________________________________________________ during camp on physicians order - one half of fee for unexpired term will be refunded. 7. Student’s Personal Property: Camp Muskoka is not
responsible for lost, stolen or damaged property. 8. Medical Updates - It is the responsibility of the Parent/Guardian to notify Camp Muskoka in
( ) ________________________________ Work Tel: __________ writing if any information on this health certificate should change between the time of registration and the time of arrival to camp (i.e. exposure
to any communicable disease, etc.). 9. I have read this complete application and I accept the conditions of enrollment. If there are any conditions
that you do not agree to please completely cross them out with black ink, initial and provide a brief explanation on an attached sheet.
Cell Tel: ____________________________________________ Other Tel: __________________________________________ Please name an alternative person that we may contact in case of an emergency: I have read and herby agree with the above stated rules, regulations, conditions and policies: Name: ____________________________________________________ Relationship with student:___________________ Parent/Guardian Signature _____________________________________________________ Date: _____________________________ ( ) _____________________________________ Work Tel: __________ Student Signature _______________________________________________________________ Date: _____________________________ ( ) _____________________________________ Other Tel: __________ 1-888-734-CAMP • www.campmuskoka.com
STUDENT HEALTH CERTIFICATE
The information in this section will be kept confidential by the Camp Muskoka staff. It is requested
______________________________________________________________________________ only for the purpose of providing the proper care to your child. The more we know about your child
the better we will be able to offer them the appropriate care. If any additional information would be
______________________________________________________________________________ helpful to staff please feel free to attach additional pages.
______________________________________________________________________________ Physician’s Name: ______________________________________ Physician’s Tel: ___________ ______________________________________________________________________________ Physician’s Address: ________________________________________________________________________________________________ ______________________________________________________________________________ Does the student have any physical or emotional needs? Please Describe: ____________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ Has the student had any operations, illness or injury within the last 12 months? Please give details: __________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ Will the student be bringing any medications to camp? Please give details: __________________________________________________________________________________________________ MEDICAL DIRECTIVES
The management will administer or authorize staff to administer the following medications without _________________________________________________________________________________________________________________________ parental notification, if necessary for your child’s welfare and good health. If there are any injections, special medications or treatments to be given at camp, explain when and how Should you the parent/guardian oppose any of the following medications please clearly cross them off of the list and provide us with a brief explanation below.
they are to be administered. ________________________________________________________________________________________ Medication
Administered for:
_________________________________________________________________________________________________________________________ Itching due to insect bites, minor skin irritations, poison ivy / oak _________________________________________________________________________________________________________________________ Such medications must be brought to camp by the student and kept in the infirmary for safety reasons. If Headache, toothache, menstrual pain, fever, earache it is necessary for your child to carry their medication with them (i.e . Epipen, Ventolin/puffers) please Headache, toothache, menstrual pain, fever, earache provide a waist pouch so that they may do so.
Is there any information that may be useful to the Camp Muskoka staff or an emergency physician? Heartburn, indigestion, upset stomach, nausea, diarrhea Broad-spectrum protection (Parents need to send a full supply) Mild sterilizing agent for cuts and scrapes Are there custodial rights that we should know about regarding your child? __________________________________ Mild sterilizing agent for cuts and scrapes _________________________________________________________________________________________________________________________ Barrier device used by First-aid personnel when dealing with situations Sterilizing agent for cleaning cuts and scrapes Special Dietary Needs. Please check all that apply Pain relief from minor burns, cuts and scrapes ❑ Other Food Allergies — Please List: ____________________________________________________ Explanation: _________________________________________________________________________________________________________

Source: http://www.chatt.hdsb.ca/~hgpps/HGP%20Web/FOV1-000ED107/FOV1-000ED01F/Muskoka%20Registration%20Form.pdf