Release Form Please fill out the information below: I, ___________________________________________ give permission for my child, _____________________________________________ to participate in the BrainWorx: A Summer Experience at Laurier offered by Wilfrid Laurier University in July 2011. I am aware of the types of activities in which the children will participate on a regular basis. I agree that photographs may be taken of camp activities, which may include my child, and may be used for marketing purposes for future camps. I hereby fully release Wilfrid Laurier University, its officers, employees, agents and assigns from any and all liability, claims, actions, damages and expenses resulting from any personal injury or other damage suffered or incurred by the above-named child as a result of participating in the BrainWorx: A Summer Experience at Laurier, notwithstanding whether any such injury, damage or otherwise is suffered as a result of the negligence of Wilfrid Laurier University, its officers, employees, agents or assigns. Signed: _____________________________________ Dated:____________________ Indicate below any information concerning your child of which staff should be aware (e.g. medical, behavioural or special needs, allergies, etc.) If medication is required for any of the above, please be sure to complete reverse. O WE RESPECT YOUR PRIVACY. The information you provide is kept confidential and will not be given to others, unless there is a medical emergency during your child’s camp. Please check here if you chose NOT to provide us with your child’s Health Card Number. Health Card Number: _________________________________________ Please print below the name and phone number of the person to be contacted in case of an emergency relating to your child. Name: _____________________________ Daytime Telephone #: _________________ Please complete this form and mail it to: Office of Continuing Studies, 75 University Ave W., Waterloo, ON, N2L 3C5. You may also drop it off in person at 202 Regina Street room R293, or fax it to: (519) 884-6063. Or scan both pages and email them as an attachment to [email protected] This form MUST be returned a minimum of TWO WEEKS before the first day of your child’s camp, to ensure your child’s space in the camp This information is collected under the authority of the Wilfrid Laurier University Act to administer the universitystudent relationship. This includes but is not limited to maintaining your academic and ancillary records, contacting you, and others on your behalf, and releasing such information as is appropriate for the operation of the university. Please visit our Privacy Co-ordinator’s web-page www.wlu.ca (under “Resources”) for more examples of potential uses of your personal information. Questions may be directed to the co-ordinator at [email protected] or 519-884-0710 ext. 3637. Administration of Medication Authorization PLEASE NOTE: It is understood that the preferred practise is that all medication be administered by the parent/guardian at home during non-camp hours. The parent/guardian shall ask the camper’s physician if the medication must be administered during the camp hours and/or if an alternative medication could be prescribed that does not require administration during camp hours. I, __________________________________________________________ authorize the administration of (name of medication) ______________________________________________________________________ to (child’s name) _________________________________________________________________________ for (reason) ____________________________________________________________________________ by the Camp Director or a staff member designated by the Camp Director. Dosage: _____________________________________________________________________________ Times of Administration: 1. _________________________________________ 2. ______________________________________ 3. _________________________________________ 4. ______________________________________ Special Instructions: ____________________________________________________________________ (e.g. “Must be taken with food.”) Side effects: _________________________________________________________________________ Stop medication if the following reaction(s) observed: _________________________________________ Has this medication been prescribed by a physician: Yes ____ No ____ Prescribing physician’s name: _______________________ Phone Number: ________________ 1. As the parent/guardian of the above named camper, I request and authorize the administration of said camper of the prescribed medication referred to above, using the procedures outlined below, by Laurier camp personnel, who I acknowledge are not medically trained to administer medication. 2. I understand that no more than the daily dose(s) is to be sent to the Laurier camp at any one time. 3. I understand and accept that if questions arise about administering the medication, the camp leader/designate, will contact the parent/guardian to come and administer the medication. Therefore it is the responsibility of the parent/guardian to insure that all medication is in the original container and all information regarding dispensing is clearly marked. 4. I also understand and accept that if problems arise with the administration of the medication: for example, (including without limitation) refusal by the camper to take the medication, complaints of side effects, or possible allergic reactions, then the camp will immediately discontinue further doses and inform the parent/guardian, at the earliest practical opportunity, as to the nature of the problem. It is then the parent’s/guardian’s responsibility to decide if the camper’s physician needs to be consulted to assess whether changes to the prescribed medication and/or administrative procedures referred to are necessary. A new copy of this medication form must be completed for any change in the medication prescribed and/or the administrative procedure referred to above. 5. I also understand and accept that the camp leader/designate can reserve the right to refuse to administer treatment to the camper if the necessary information is not provided by the parent/guardian. 6. I confirm that I have asked the camper’s physician if the medication must be administered during the camp hours and he/she has also responded and advised as such. 7. The information will be used only to assist with meeting the health needs of the camper. 8. If there are any questions about the information gathered on this form, please contact the camp leader directly. 9. This request will terminate at the end of each individual camp enrolment period. 10. I hereby release the Wilfrid Laurier summer camp, its employees and agents from all manner of actions, causes of action, suits, losses, damages or injuries, however caused, arising out of the administration or failure to administer medication as provided herein, and I do also hereby indemnify the said camp, its employees or agents for any losses or damages sustained by them as a result of such actions or proceedings being commenced against them by myself or the camper or any other parent or guardian of said camper. 11. I hereby acknowledge that I have read and fully understand the terms set out herein. ________________________________________________ _________________________________ Parent/Guardian’s Signature Date PLEASE FILL OUT FORM COMPLETELY Prior to administering, medication must be authorized by Director, Supervisor or designate.
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