Medical Form for children - Montréal-Laval Respite

Name of the family*

Ex.: Côté-Tremblay

General Information

Name*

First name Last name

Phone number*

Date of birth*

Gender*

M
F
Other

Age at Respite*

Health insurance number (without spaces)*

Expiration date*

Parent/Legal Guardian's email*

Legal Guardian

Name*

First name Last name

Relationship*

Emergency contact on site

Name

First name Last name

Phone

Emergency contact (out of the Family Respite site)

Name

First name Last name

Relationship

Phone

Medical Informations

Please indicate who you are filling out the form for*

Child with cancer
Other child who does not have cancer

Diagnosis*

Date of diagnosis*

Date of relapse

Date of remission

End of treatment date

Date of marrow transplant

Type of transplant

Vaccines

Has your child received a tetanus vaccine since 2012?*

Yes
No

Has your child received the chicken pox vaccine?*

Yes
No

Has your child had chicken pox?*

Yes
No

Illnesses

Does your child suffer from or is he or she affected by:

Skin problems?*

Yes
No

If yes, provide details:

Vascular problems?*

Yes
No

If yes, provide details:

Heart disease (hypotension, hypertension, infarct, etc.)?*

Yes
No

If yes, provide details:

Respiratory problems/Asthma?*

Yes
No

If yes, provide details:

Diabetes?*

Yes
No

If yes, provide details:

Joint/ bone problems?*

Yes
No

If yes, provide details:

Recent trauma/ fracture?*

Yes
No

If yes, provide details:

Mobility problems?*

Yes
No

If yes, provide details:

Use a walking aid (wheelchair, cane, other)?*

Yes
No

If yes, provide details:

Does he need help with activities of daily living?*

Yes
No

If yes, provide details:

Does he wear prostheses/orthotics?*

Yes
No

If yes, provide details:

Recent surgery (in the last six months)?*

Yes
No

If yes, specify the nature of the intervention and the date :

Has he received antibiotics in the last six months?*

Yes
No

If so, for what reason:

Does your child have a central line ? (PICC line, PAC, other)*

Yes
No

If yes, provide details:

Language or communication problems?*

Yes
No

If yes, provide details:

Attention deficit troubles, with or without hyperactivity?*

Yes
No

If yes, will your child take medication during the respite?

Does your child have a visual and/or hearing limitation?*

Yes
No

If yes, specify:

Other health problems: (check and specify)

Headaches
Cold sores (cold sore)
Stress/Anxiety
Depression
Insomnia
Epilepsy
Ear infections
Athlete's foot/Plantar warts
Other

Specify

Allergies and intolerances

Allergies?*

Yes
No

Medications?*

Yes
No

If yes, provide details:*

Food?*

Yes
No

If yes, provide details:*

Other allergies?*

Yes
No

If yes, provide details:*

Is an Epipen needed?*

Yes
No

Dietary requirements

Check:

Kosher/Hallal
Pork-free, gelatin-free
Vegetarian
Vegan/Vegan
Lactose free
Gluten-free
Other

Specify if needed

Please add any details, lifestyle issues or conditions that might help us to know and understand you better. Together, we can ensure that you get the most out of your stay.

Consent form for adults and children over 14 years old

Consent

I authorize that photos and videos taken of myself during the activity be used to represent Leucan's mission. I authorize that my name, images, voice and comments be used without limit of territory, media or language to promote Leucan's mission for a period of one year.

Consent*

I agree to respect all instructions and guidelines of the activity organized by Leucan.

Consent*

I acknowledge that my participation in the activity may involve risks, and I hereby assume and freely accept all risks arising from my participation in this activity. I acknowledge and accept that Leucan declines all responsibility for the risks that my participation in the activity may entail and that Leucan cannot be held responsible for any damages of any kind (physical, moral or material) that I may suffer in connection with my participation in this activity. Therefore, I agree to release and hold harmless Leucan, the event organizers, volunteers, sponsors, partners and their respective employees and agents present at this activity from any and all liability for loss, damage or injury to myself as a participant or to my property that may arise or occur in connection with my participation in this activity, and I waive all rights with respect to the foregoing.

I, the undersigned, (name of the participant), accept the terms and conditions of this activity.

First name Last name

Consent form for children under 14 years old

Consent

I authorize that photos and videos taken of my child during the activity be used to represent Leucan's mission. I authorize that my child's name, images, voice and comments be used without limit of territory, media or language to promote Leucan's mission for a period of one year.

Consent*

I agree to respect all instructions and guidelines of the activity organized by Leucan.

Consent*

I acknowledge that my child's participation in the activity may involve risks, and I hereby assume and freely accept all risks arising from their participation in this activity. I acknowledge and accept that Leucan declines all responsibility for the risks that my child's participation in the activity may entail and that Leucan cannot be held responsible for any damages of any kind (physical, moral or material) that my child may suffer in connection with their participation in this activity. Therefore, I agree to release and hold harmless Leucan, the event organizers, volunteers, sponsors, partners and their respective employees and agents present at this activity from any and all liability for loss, damage or injury to my child as a participant or to my child's property that may arise or occur in connection with their participation in this activity, and I waive all rights with respect to the foregoing.

I, the undersigned, (name of the parent/legal guardian), authorizes the children mentionned above to participate in this activity and accept the terms and conditions of this activity.

First name Last name

Medical Form for children - Montréal-Laval Respite

Medical Form - Family Respite Montréal-Laval - May 2023 - Children

General Information

Legal Guardian

Emergency contact on site

Emergency contact (out of the Family Respite site)

Medical Informations

Vaccines

Illnesses

Allergies and intolerances

Dietary requirements

Consent form for adults and children over 14 years old

Consent form for children under 14 years old

Partners