Medical form for parents - Montréal-Laval Respite

Family name*

(ex. : Côté-Tremblay)

General Information

Name*

First name Last name

Phone number*

Email*

Gender*

M
F
Other

Health insurance number (without spaces)*

Expiration date*

Languages spoken*

Have you been trained as

Emergency worker
Nurse
Paramedic
Doctor

Emergency contact (if your spouse is not at the Respite)

Name

First name Last name

Relationship

Phone number

Vaccines

Have you been vaccinated for tetanus since 2012?*

Yes
No

Medical information

Do you suffer from or are you 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:

Diabetes?*

Yes
No

If yes, provide details:

Epilepsy?*

Yes
No

If yes, provide details:

Respiratory problems ?*

Yes
No

If yes, provide details:

Recent surgery (less than six months)?*

Yes
No

If yes, provide details:

Recent trauma?*

Yes
No

If yes, provide details:

Joint/bone problems?*

Yes
No

If yes, provide details:

Movement problems?*

Yes
No

If yes, provide details:

Are you pregnant?*

Yes
No

If yes, for how many weeks?*

Do you take medications?*

Yes
No

If yes, which?

Other illnesses?

Headache
Stress and anxiety
Insomnia
Depression
Mobility problem
Visual disability
Hearing disability
Plantar wart
Athlete's foot

Specify if needed

Allergies and intolerances

Medications?

Allergies
Intolerances

If yes, specify*

Food?

Allergies
Intolerances

If yes, provide details:*

Other allergies?*

Yes
No

If yes, provide details:

Do you need an Epipen?*

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

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.

Medical form for parents - Montréal-Laval Respite

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

General Information

Emergency contact (if your spouse is not at the Respite)

Vaccines

Medical information

Allergies and intolerances

Dietary requirements

Consent

Partners