Eurekacamp.ca

EUREKA OUTDOOR CAMP – REGISTERED CAMPERS 2011

Please review the following information, SIGN WHERE INDICATED and return to the office as soon
as possible. It will not be possible for your camper to participate in activities if we do not receive this.
CAMPER’S NAME:
PARENT/GUARDIAN’S NAME:

DROPPING OFF/PICKING UP YOUR CAMPER

It is expected that the person who brings your camper will be the one to pick him/her up at the end of
camp. However, if you know that you will be sending someone else, either to drop off or pick up, please
indicate their name and telephone number below.
 I will be dropping off and picking up my camper ______________________________________________________________________________
Name
Relationship to Camper
 I give permission for the person named below to: o Pick up my camper o Drop off my camper Name
Relationship to Camper
______________________________________________________________________________ Signature of Parent/Legal Guardian
Date

VISITORS

There may be persons that you do not want to have access to your camper. If this is the case, please note their name
and relationship to the camper below. We will then be authorized to block access to the camper by that person:
Name:
Relationship to Camper:
__________________________________________________________________________________________________________________________________________________________________________ CAMPER PICK UP - On the last day of camp you or your designate will be asked to sign below before your camper will be released. Please
ensure that you/designate has ID available.
DO NOT SIGN THIS UNTIL THEN

I declare that I have picked up
_______________________________________________________________________________________________________________
Camper’s Name

________________________________________________________________________________________________________________
Signature of Parent/Legal Guardian/Designate
CAMP PROGRAM
Out – Trips
It is anticipated that part of our program may include some time off site, in order for children and
particularly adolescents to practice their team building and camp craft skills. Out Trips are often a high
light of your camper’s experience. We would like to ensure that you are aware that your camper may be
off site some time during his/her stay. Your signature is required for your camper to participate in
out trips.

______________________________________________________________________________ Signature of Parent/Guardian
Date

Swimming
Swimming is part of our camp program this year. The information below will enable us to support your
camper’s goals for swimming: Please note that a lifeguard will be present at all times designated for
swimming and life jackets will be worn for all boating activities. Your signature is required for your
camper to participate in swimming.

o I have concerns about my child in the water which are: o ________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________ o Beginner o Intermediate o Comfortable in deep water _____________________________________________________________________________
Signature of Parent/Guardian
Date
22151 Wilson Avenue Richmond, BC., V6V 2P6 604-520-1155 EUREKA OUTDOOR CAMP – REGISTERED CAMPERS 2011

CAMPER’S NAME:
PARENT/GUARDIAN’S NAME:

PARENT/GUARDIAN AUTHORIZATION FOR HEALTH CARE
If an emergency arises whereby the camp staff judge that the use of medication is required in order to
preserve the life of the camper and contact with a physician or parent/guardian is not immediately
possible, the medication will be administered without consent, ie Epinephrine may be needed
immediately in cases of severe allergic reaction.
The information I/we have given accurately reflects the health status of the camper to whom it pertains.
The person described has permission to participate in all camp activities except as noted by me and/or an
examining physician. I give permission to the physician selected by the camp to order x-rays, routine
tests, and treatment related to the health of my child for both routine and emergency situations. I
understand that if the camper appears ill, has a communicable infection or has been recently exposed to a
communicable infection, or, has an injury that would prevent full participation in the program, it may not
be possible for the camper to attend the session.
If I cannot be reached in an emergency, I give my permission to the physician to hospitalize, secure
proper treatment for, and order injection, anesthesia, or surgery for this child. I understand the
information I have given will be shared on a “need to know” basis with camp staff. I give permission to
photocopy this form. Also, the camp has permission to obtain a copy of my child’s health record from
providers who treat my child and these providers may talk with the program’s staff about my child’s
health status.
Signature of Parent(s)/Guardian
Date
Relationship to Camper

IMMUNIZATIONS

If your camper has not been fully immunized to the extent recommended for his/her age, please sign the
following statement:
I understand and accept the risks to my child from not being fully immunized.
22151 Wilson Avenue Richmond, BC., V6V 2P6 604-520-1155 Signature of Parent(s)Guardian
Date
Relationship to Camper

MEDICATION

• ALL MEDICATION MUST BE BLISTER PACKED.
• PLEASE PROVIDE ENOUGH MEDICATION FOR EVERY DAY OF CAMP PLUS 2
• IN THE EVENT OF A MIS-MATCH, THE INSTRUCTIONS ON THE BLISTER
PACKAGING WILL BE FOLLOWED.
 This camper will not take any daily medications while at camp  This camper will take the following medications while at camp (“Medication” is any substance a person takes to maintain and/or improve their health. This includes vitamins and natural remedies)

NON PRESCRIPTION MEDICATION FOR THE MANAGEMENT OF ILLNESS OR INJURY
Listed below are non prescription medicines that may be stocked in the Camp Health Centre. They are
used on an as needed basis to manage illness and injury. Please cross out the medications your camper
should NOT be given.
o Acetaminophen (Tylenol, minor
o Dextromethorphan cough syrup
o Aloe (relief of sunburn)
o Dimenhydrinate (Gravol, motion/travel
o Antibiotic cream (sores/scrapes)
o Antihistamine/allergy medication
o Diphenhydramine antihistamine
o Bismuth subsalicylate (Kaopectate,
o Ibuprofen (Advil, Motrin, minor
o Calamine Lotion (bites/stings)
22151 Wilson Avenue Richmond, BC., V6V 2P6 604-520-1155 o Laxatives ( Ex-Lax – constipation)
o Lice Shampoo/cream
ALLERGIES
(You will be asked to describe the camper’s allergies and the reaction seen when you drop off your
camper).
MEDICINE
ENVIRONMENT
GIVE BRIEF DETAILS
SENT WITH
CAMPER OR
HAY FEVER,
AVAILABLE AT
STINGS ETC

I give permission for all medications to be administered by camp staff as indicated.
_____________________________________________________________________________________
Signature of Parent(s)Guardian
Date
Relationship to Camper
22151 Wilson Avenue Richmond, BC., V6V 2P6 604-520-1155
DIET/NUTRITION
 This camper eats a regular diet
 This camper eats a regular vegetarian diet (No meat, Yes eggs and dairy)
 This camper has special food needs (please describe below or attach sheet)
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ IS THERE ANYTHING WE FORGOT TO ASK?
Please use the space below to describe any concerns that you may have with regard to your camper’s health or their ability to fully participate in the program that have come up since your application was received. _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ ________________________________________________________________________ 22151 Wilson Avenue Richmond, BC., V6V 2P6 604-520-1155

Source: http://www.eurekacamp.ca/PDF/EurekaRegisteredCampers.pdf