Medical Form for Parents

Select one:*

Week 1 - July 24 to 29
Week 2 - July 31 to August 5

Family name*

(ex. : Côté-Tremblay)

General Information

Name*

First name Last name

Address*

City*

Postal Code*

Home phone

Cell*

Email*

Marital status*

Date of birth*

Age at Camp*

Gender*

M
F

Weight (kg)*

Health insurance number (without spaces)*

Expiration date*

Languages spoken*

Have you been trained as

Emergency worker
Nurse
Paramedic
Doctor

Have you already attended the Camp?*

Yes
No

If yes, what is your Camp name?

General health

Excellent
Good
Average
Poor

Emergency contact (if spouse is not at Camp)

Name

First name Last name

Relationship

Home phone

Cell

Vaccines

Have you been vaccinated for tetanus since 2012?*

Yes
No

Have you received at least 2 doses of the Covid-19 vaccine?*

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:

Do you wear a prosthesis?*

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

If yes, specify

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

Diet

Check:

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

Specify if you have a diet

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

Medical Form for Parents

Medical form 2022 Camp - Parents

General Information

Emergency contact (if spouse is not at Camp)

Vaccines

Medical information

Allergies and intolerances

Diet

Partners