Name:______________________________________________________Age:_____________________

Address:______________________________________________Tel. No.: ________________________
____________________________________________________________________________________

Parents' Name:_____________________________  Phone number and location parent or guardian can be reached for emergencies During camp time:     ________________________________________________

Alternate contact person in case of emergency during camp:
_____________________________________________________________________________________

Name of physician: ___________________________________ telephone no.: _______________________

Address:______________________________________________________________________________

Sask. Health Services No.:  _____________________________  Date of last tetnus shot:________________

Chronic conditions:

Allergies	Yes  No	Illness	Yes  No	Other	Yes  No
Asthma	___  ___	Diabetes	___  ___	Bedwetting	___  ___
Hay Fever	___  __	Epilepsy	___  ___	Nightmares	___  ___
Food	___  ___	Heart Ailment	___  ___	Sleepwalking	___  ___
Other (list)	______________			A.D.D.	___  ___

If you are allergic to certain types of food, please specify:
______________________________________________________________________________________

Are you currently on medication or has medication recently seen discontinued: __________________________

If yes, please identify the medication and the illness they have been prescribed for:
______________________________________________________________________________________

Do you have any other medical problems that are not listed above? ___________________________________
______________________________________________________________________________________

I hereby certify that, to the best of my knowledge, the information contained in this form is true, correct and complete. I hereby authorize Camp Tapawingo Committee and/or its employees to obtain such medical services as they deem are required in regards to the camper named above.

Date: _______________________ Parent's Signature: ___________________________________________

Please feel free to contact our camp nursing coordinator, Elizabeth Moar (764-4763) should you wish to discuss your child’s special needs.  Camp Tapawingo welcomes all campers and will try to adapt to needs or individual campers as best we can. We will do our best to place campers who happen to be ill at the time of their chosen camp in an alternate camp.

We would appreciate this Medical Form Returned to the Registrar as soon as possible.  If your camp is less than 20 days away, please take with you to camp.