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Please do not write in this space
CONSENT FOR MEDICAL TREATMENT
If necessary do we have permission to give your child
Yes___ No___ Acetaminophen-Tylenol or Tempra (fever, headache, general pain)
Yes___ No___ Dimenhydrinate-Gravol (nausea, vomiting)
Home Address _____________________________________________________
Yes___ No___ Ibuprophen-Advil, Ibuprofen, Motrin (pain, fever, anti-inflammatory) Yes___ No___ Cough Suspensions-Benylin, Triaminic, Robitussin
City ________________________ Province ________ Postal Code ___________
Yes___ No___ Antacids-Gaviscon, Maalox, Mylanta, Tums, Rolaids
(upset stomach, acid reflux, heartburn)
Yes___ No___ Antibiotic Creams-Polysporin (wounds, cuts, abrasions)
Ontario Health Card No. ___________________________________ Initial _____
Yes___ No___ Laxatives-Milk of Magnesia (constipation)
Parent’s/Guardian’s Home Phone _______________ Work __________________
CONSENT FOR FOLLOWUP
In case of illness, notify
We would like to keep in touch with your child over the next year.
Address ________________________________ Phone ____________________
Yes___ No___ Ruby (Mailbox Bible Club Administrator) Yes___ No___ My camper’s Bible teacher
Family Physician’s Name _____________________________________________
City ___ _____________________ Province______ Postal Code _____________
Phone Number (_______) __ _________________________________________
In case of emergency in the event that we cannot be reached for
immediate consultation, I hereby give permission to the camp leadership
PRESENT PHYSICAL CONDITION:
Weight _________ Height ________
to hospitalize, secure proper treatment for, and to order medications,
Are there any Physical Abnormalities? If so, what __________________________
anesthesia or surgery for the camper as named above.
If insufficient information is given on this medical form, I give you
permission to acquire the medical information from our physician.
Emotional Stability of Camper: Hyperactive ___ Developmentally Challenged ____
While every precaution is taken for the safety and good health of our campers, Mill Stream Bible Camp, its directors and staff members are
Emotional Problems____ Anger Management Concerns____ Other____________
hereby released from any and all liability in the event of an illness,
accident or misfortune that may occur to the camper. Parents are responsible for any additional expenses that may occur above the
Pediculosis (Head Lice) ___ Impetigo ___ Athlete’s Foot ___ Plantar Warts___
Other infection: ___________ _________________________________________
To the best of my knowledge, this child is in good health and by enrolling
my child I give permission for involvement in all camp activities except as
May this camper participate in all Camp activities, including swimming?
By enrolling my child I give permission for photo/video media of my child
to be used for camp promotions via printed or electronic material,
If no, which activities must be avoided? _________________________________
Date _________ Parent’s/Guardian’s Signature _________________________
To be completed prior to coming to Camp. Bring with you to Camp on check-in day.
MEDICATION TO BE GIVEN AT CAMP
Is this camper subject to: (Please answer YES or NO to each)
Reason for taking medication
____ Chronic Ear Infections ____ Bed Wetting
____ Severe Stomach Aches ____ Homesickness
Treatment for the above condition(s): ___________________________________
All medications must be left with the Camp Nurse.
Some exemptions may be at the discretion of the Camp Nurse.
Mill Stream Bible Camp & Retreat Centre is required by law to operate with at a
minimum, qualified First Aid personnel on the grounds at all times.
The camp has a physician on call and volunteer nurses or first aid personnel are on the
Mill Stream Bible Camp & Retreat Centre intends to provide safe and conscienceous
Has the camper been exposed to the above communicable disease within the
care for your child while at camp but wish to make you aware of the limitation that Mill
Stream Bible Camp & Retreat Centre operates under the guidelines of the Ontario Camping Association and the Ontario Ministry of Health, and is only required to provide
What disease _____________________ When ___________________________
Mill Stream Bible Camp & Retreat Centre believes that your privacy is important for you
If camper has been exposed to any of these diseases, the Camp
as an individual and family. We are committed to ensuring that your personal
Leadership must be notified BEFORE coming to Camp. We reserve the right to
information is treated professionally. To safeguard the personal information entrusted to Mill Stream Bible Camp & Retreat Centre and to comply with the Personal Information
refuse admission of any camper based upon our health concerns as indicated by
Protection and Electronic Documents Act
("PIPEDA") and any other applicable
legislation, Mill Stream Bible Camp & Retreat Centre is committed to the principles as
. This policy is available for your viewing upon your request.
We do not require a physician’s signature on this medical form
and therefore are not responsible for any medical examination expenses.
Please do not write in this space below
PAST HOSPITALIZATIONS AND REASONS:
Please complete consent form on reverse page
INFORMATION TECHNOLOGY AND COMMUNICATIONS Mitigating Motion Sickness in Ground Vehicles J.T. Coyne,1 R. Stripling,1 E. Rovira,2 D. Hunter,3 J.V. Cohn,1 K. Brendley,3 G. Zwick,2 and G. Carter2 Introduction: Motion sickness (MS) represents a challenge to many warfighters, particularly those in command and control vehicles (C2V). Research by the U.S. Army and NASA1 suggests that as many as 9
Glossary of Cardiovascular Terminology Abdomen - The area of the body between the bottom of the ribs and the top of the thighs. Abdominal aorta - The portion of the aorta in the abdomen. Ablation - Elimination or removal. ACE (angiotensin-converting enzyme) inhibitor - A drug that lowers blood pressure by interfering with the breakdown of a protein-like substance involved in bloo