Medical Information Form

Please fill out a form for each camper. If you have attended camp before, new submissions are NOT required for Summer 2025 sessions. Please email us to confirm that nothing has changed on the forms.

If you need to explain further or anything in more detail, please reach out to our camp administrator admin@yourneighbourhoodcamp.com

Camper's Name

First Name

Last Name

Birthdate

YYYY

Age

Gender

Male

Female

Non-Binary

Two-Spirit

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian Information

Parent/Guardian 1

Legal name

First Name

Last Name

Phone Number

(###)

###

####

Parent/Guardian 2

First Name

Last Name

Phone Number

(###)

###

####

MANDATORY Emergency Information

Please provide us with someone other then parents/guardians who are able to help such as grandparents or a family friend in case of an emergency.

Emergency Contact's Name 1

This should not be the parent or guardians listed above.

First Name

Last Name

Relationship to Camper

Phone Number

(###)

###

####

Emergency Contact's Name 2

First Name

Last Name

Relationship to Camper

Phone Number

(###)

###

####

Medical Information

Does the camper have any diagnosis or suspected diagnosis for any of the following allergies, medical conditions, psychiatric or neurodevelopment disorders?

If yes, please describe in detail.

Does the child have any limitations or pose any safety concerns to themselves or to others that may or may not require modifications or additional support during regular independent camp activities, such as independent play in an open space or wooded area, independent walking, running, climbing stairs, jumping, crawling, carrying a backpack, dressing, eating, washing or toileting?

If yes, please explain in detail below as well as email the camp director to ensure accommodations are put into place before the child's first day of camp. We are a hands off camp and campers NEED to be able to change and go to the washroom independently.

WIll your child carry any of the following medications during camp hours with them?

Additional forms required for use for medication during camp hours.

If your child up to date on their immunizations?

Is the camper prescribed medication for use at home that you think we should be aware of?

If yes, please share below.

Is there anything else that you would like to share about your child's development or health that would help us understand their needs to ensure they have a fantastic camp experience?

You must read the Informed Consent and Acknowledgement and Medical Release and Authorization below and check off you have read them.

By acknowledging, agreeing and typing your name, phone number and address below, I am delivering and electronic signature that will have the same affect as an original manual paper signature. This selection will be as equally binding as an original manual paper signature.

Informed Consent and Acknowledgement: I hereby give my approval for my child’s participation in any and all activities prepared by Your Neighbourhood Camp Inc. during the selected camp session. In exchange for the acceptance of said child’s candidacy by Your Neighbourhood Camp Inc. camp sessions, I assume all risks and hazards incidental to the conduct of the activities and release, absolve and hold harmless Your Neighbourhood Camp Inc. and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of travelling to, participating in, or returning from selected camp sessions. In case of an injury to said child, I hereby waive all claims against Our Neighbourhood Camp Inc., including all counsellors and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all camp activities. Some of these injuries include but are not limited to the risk of fractures, paralysis, or death.

Agree

Medical Release and Authorization: As the parent or guardian of the named child, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed. Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named child. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me. Permission is also granted to Your Neighbourhood Camp Inc., and its affiliates including Directors and Counsellors, to provide the needed emergency treatment prior to the child’s admission to the medical facility. In situations that are not a medical emergency, permission is hereby granted to Your Neighbourhood Camp Inc. and its affiliates including Directors and Counsellors, to provide needed minor first aid treatment to said child. I release authorized on the dates and/or duration of the registered season. This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances and non-emergency circumstances, for the protection of the minor child, in my absence.

Agree

Confirmation: By acknowledging and confirming above, I am delivering an electronic signature that will have the same effect as an original manual paper signature. The electronic signature will be as equally binding as an original manual paper signature.

Agree

Parent/Gaurdian Name

First Name

Last Name

Parent/Guardian Phone

(###)

###

####

Parent/Guardian Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Thank you for filling out your campers Medical Information Form.

We keep both electronic and paper copies in our offices and on hand during camp.

You may be contacted further if your child has allergies, asthma, medications during camp or any other accommodations that may be needed.

Please contact us if you have any questions.