Kiddie Day Camp Emergency and Health Information Form

Camper Information

Camper`s Name
Age
Date of Birth (dd / mm / yyyy)
/ /

PARENT / GUARDIAN 1:

Name
Phone
Cell

PARENT / GUARDIAN 2:

Name
Phone
Cell

IN CASE OF EMERGENCY NOTIFY:

Name
Relationship
Phone
Cell
Alternate Name
Relationship
Phone
Cell

HEALTH INFORMATION:

Current Medication
Dosage
Health Card No.
Version Code
Drug Allergies
Food Allergies
Does your child have any emotional/developmental issues: (i.e. Hearing,/Speech/ Developmental Delay?)
Does your child require assistance with toileting?: Please specify

Business Office: 14-441 Stonehenge Drive, Ancaster, Ontario, Canada L9K 0B1,
Tel.: 416.427.3171, Fax: 905.304.2982
Email: Dianne@campakomak.com Website: www.campakomak.com

Summer Address: 240 Akomak Road, Ahmic Harbour, Ontario, Canada P0A 1A0,
Tel.: 705.387.3810, Fax: 705.387.0077