The information on this form will be used at the discretion of Surprise Lake Camp health 
care staff, to ensure proper care and attention is given to the of the participant, All 
information is personal and confidential. 
	Name: ……………………………….	Date of Birth: ……………………	_ 
	Address: ………………………….. 	Height: …………	Weight: ……………	_ 
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	Parent/Guardian: ……………………	Phone: Home (……) ……………… _ 
   Work (……) ………………
Address (if different from above):
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…………………………………………………...
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Emergency Contact Information: 
	1. Name: 	Relationship 	_ 
	Phone Number: Home (……..) 	Work: (……) ……………………	 _ 
	Address: ………………………………………………………………………………..	_ 
	2. Name: 	Relationship 	_ 
	Phone Number: Home (……)  	Work: (……) 	_ 
	Address: 	_ 
	Provincial Health Care No: 	Other Health Care No: 	_ 
	Family Doctor 	Phone: (…...) 	_ 
The camp program may include swimming, hiking, boating and other physical activities. 
Does the participant suffer from any physical or emotional disorder that would prevent 
him or her from participating fully in this program? If yes, please state details.
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Do you have any special instructions for the camp staff regarding the participant's health 
care or diet? 
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Does the participant have allergic reactions to such things as drugs, food, insect stings? 
Please list any allergies, type of reaction and treatment given. 
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If female, has this person menstruated? 	_ Yes    No
	If not, has she been told about it?                      Yes    No		_ 
Is the participant currently subject to any of the following? 
•	Arthritis 
•	Convulsions 
•	Sleepwalking 
•	Respiratory ailments 
•	Ear trouble 
•	Nightmares 
•	Bedwetting 
•	Motion sickness 
•	Headaches 
•	  Other (please specify) 	_ 
Please give details of usual treatment should the condition occur: 
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Are there any chronic conditions or recent illnesses of which staff should be aware? 
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Please specify details of medications (prescribed or non- prescribed) or 
treatment required for the above: 

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Please list any medication the participant is bringing to camp. This must be clearly 
labeled and given to the camp health care staff upon arrival at camp. 
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On occasion, campers become ill at camp and require attention from our health care 
staff. Please list the non prescription medication, if any, the camp health care staff has 
permission to administer and under what conditions (i.e. children's Tylenol for a fever, 
cough syrup for a cough). 
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	Date of last tetanus shot: …………………………….	
Corrective lenses required?          Yes    No 	_ 
Contact Lenses? 		      Yes    No
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Any other comments? 
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Every care any attention will be given to the health and comfort of all campers
I hereby authorize Surprise Lake Camp to secure such medical advice and services as 
may be deemed necessary for the health and safety of myself or my child (or ward). 
	Signature of parent/guardian 	
…………………………………..                    Date …………………………. 	_