HEALTH AND CONSENT FORM

HEALTH AND CONSENT FORM
Section 3 Forms and Information
(for participants under 18 years of age)
A. PARTICIPANT’S Personal information (please print)
Surname: _______________________________________ Given name: ______________________________ Sex: ______
Age: _____ Birth date (Y-M-D): ___________________ Health card no. (recommended): ___________________________
Home address: ________________________________________________________________________________________
City, postal code: _____________________________________________ Phone: (
)_____________________________
B. Emergency contact in case of illness
Day – Name: __________________________________ Relationship: ________________ Phone: (
)_______________
Night – Name: ________________________________ Relationship: ________________ Phone: (
)_______________
Family doctor’s name: ________________________________________________ Doctor’s phone: (
)_______________
C. Personal medical conditions and special needs (attach further information if necessary)
1.
2.
Does the participant have any allergies?* (check 3 for ‘yes’)
Insect
Plant
Food
Drug
Other
Do any of the following medical conditions apply to the participant? (check 3 for ‘yes’)
Diabetes
Rash
Contact lenses
Asthma
Epilepsy
Heart condition
Recent illness/operation
Other
3. If you have checked 3 any of the boxes in questions 1 and 2 above, please provide details:
________________________________________________________________________________________________
4.
Will this participant be on medication while at the field centre? (If yes, please describe.)
________________________________________________________________________________________________
5.
Describe any food restrictions (e.g., religious, vegetarian, etc.).
________________________________________________________________________________________________
6. Describe any night-time problems.
________________________________________________________________________________________________
*Note: Participants with anaphylactic conditions must be accompanied with two epipens and a copy of the medical response plan.
D. Consent of participation
I, the parent/guardian of the above participant (participant’s full name) _________________________, give consent for him/her to
participate in a field trip at the Albion Hills Field Centre from (date) ______________________to (date) ______________________.
In case of emergency, if I cannot be reached, an alternative adult whom I have asked to be on call and who is willing to be
temporarily responsible for my child is:
Full name: ________________________________ Phone (day): (
)______________ Phone (night): (
)______________
Address: ____________________________________________________ City, postal code: _____________________________
Full name of parent/guardian: ______________________________________ Relationship: _____________________________
Signature of parent/guardian: ______________________________________ Date: ___________________________________
The above information is collected under the Conservation Authorities Act. It will be held in confidence during the stay of the participant and returned
after the visit. If you have any questions regarding the collection and use of this information, please contact the field centre supervisor.
30