Medical History

Camper Information

Camp Ak-O-Mak has a full-time infirmary attendant & a physician on call or on site 24 hours a day. Hospitals are 45 minutes away in Parry Sound and Huntsville. The following medical history / health forms support the health & safe care of your daughter. All information provided is private and confidential.
First Name
Last Name
Date of Birth (dd / mm / yyyy)
/ /

PARENT / GUARDIAN NAME:

Home Phone
Day/Cell Phone
Additional Day/Cell Phone
E-mail
Home Street Address
City
Province / State
Country
Postal / Zip Code
If not available in an emergency, notify:
Name
Relationship
 
Home Phone
Work/Cell Phone
 

INSURANCE

Ontario Residents: Health Card # & Version Code: MANDATORY
Number:
Version Code:
Travel Insurance Information:
Camp Ak-O-Mak carries a mandatory Student Emergency Medical Insurance policy in Canada providing coverage up to $100,000. This medical coverage is for non-Canadians & out-of-province campers who must also be students in order to qualify. The cost for non-Canadians is $5.00 per day & out-of-province Canadians is $2.00 per day. This cost is in addition to your daughter’s tuition and will be added to your invoice, calculated according to the length of her stay upon registering. “Personal Medical Items” (including splints, tensors, slings, wound/dressing materials etc.) and non-OHIP covered items will also be invoiced to the camper’s refundable expense account. We strongly suggest all non-Canadians traveling to Camp purchase Travel Insurance for their stay in Canada.

CURRENT MEDICATION: YES NoNE

MEDICATION DOSAGE FREQUENCY

Please identify medication taken during the school year that the camper does not take during the summer.

IMPORTANT: If your child has any unusual health conditions as listed below please check the box.

Anaphylaxis Not to receive certain medical treatments for Religious reasons

Please explain

ALLERGIES

MEDICATION ALLERGIES: (LIST ALL) DESCRIBE REACTION
FOOD ALLERGIES: (LIST ALL) DESCRIBE REACTION

My daughter has experienced
the following in the past:

1 A recent injury, illness or infectious disease 2 Chronic or recurring illness / condition
3 Surgery / Hospitalization 4 Seizure disorder
5 Heart Murmur / Heart Problems 6 Asthma
7 Diabetes 8 Bedwetting
9 Frequent ear infections 10 Head injury / loss of consciousness
11 Musculoskeletal problems (spine, knees, ankles, shoulders) 12 Constipation / diarrhea / digestive problems
13 Attention/Learning challenges / Emotional issues 14 Skin Problems (rashes, acne, itching etc.)
15 History of eating disorder 16 Cultural or religious reasons for not swimming during menstruation?
If you've selected one of the points above, please explain (noting the number of the question)
Physical restriction to Activities:
Has your daughter sustained an injury that will limit her participation? (What adaptations are necessary?)

 

DIETARY RESTRICTIONS

Does not eat:
Red meat Pork Poultry
Eggs Dairy Products Seafood
Fish Other (please describe)

ILLNESSES / immunization UPDATE

Please give dates of last immunization update:
Tetanus
Measles
Meningitis Vaccine
Mumps
Rubella
Varicella (Chicken Pox)
Flu Shot
I Confirm that 's immunizations are up to date unless otherwise specified above.
Your Name Signature

Parent/Guardians: This health history is correct and complete as far as I know. The person herein described has permission to engage in all camp activities except as noted. I hereby give permission to the Camp to provide routine health care, administer prescribed medications and seek emergency medical treatment including ordering x-rays or routine tests. I agree to the release of any records necessary for treatment, referral, billing or insurance purposes. I give permission to the camp to arrange necessary, related transportation for my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the Camp to secure and administer treatment, including hospitalization, for the person named above. This completed form may be photocopied for trips out of camp.

I Agree

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