Big Brother Big Sisters x ESQ Participant Health Form

Purpose of the Participant Health Information Form: The purpose of this form is to collect your child’s necessary health information for precautionary reasons and/or in case of any emergencies during their attendance at our program. This form will ask for information about your child’s allergies, asthma/inhaler, prescribed medications, treat/snack consent (if applicable), and anything else you would like us to know about your child’s physical or mental health to protect their safety while in attendance in our programs. We thank you for taking the time to provide the most up-to-date and accurate health information about your child. Completion of this health information form is required to register your child. Updates to the form can be submitted later by email to Engineering Outreach staff.
Child's Name

Allergies

Does your child have any allergies?(Required)
Does your child require an EpiPen? (Please note, Engineering Outreach does not store personal EpiPens overnight for campers. Please ensure all Epi-Pens have not exceeded their expiry date.)

Asthma/Inhaler

Does your child have asthma and require an inhaler during program?(Required)
Please indicate the severity of the allergy if yes.

Medication

PLEASE NOTE: It is understood that the preferred practice is that all medication be administered by the parent/guardian at home during non-camp/program hours. The parent/guardian shall ask the camper’s physician if the medication must be administered during the camp/program hours and/or if an alternative medication could be prescribed that does not require administration during program/camp hours.
Will your child be taking any prescribed or over-the-counter medications while at the enrolled program/camp (prescription or homeopathic)?(Required)
PLEASE NOTE: Prescription/over-the-counter medication brought to camp must be in its original packaging. Prescription medication must also be labelled with the doctor’s name, child’s name, dosage, schedule, route, and date. If yes to the above question, please answer the following questions:
How will the medication be administered?
Is refrigeration required?
Has the medication been prescribed by a physician?

Additional Information

Administration of Medication Signature

  1. As the legal parent/guardian of the above named participant/camper, I request and authorize the administration of said camper of the prescribed medication referred to below, using the procedures outlined below, by the University of Waterloo program 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 UW program/camp at any one time.
  3. I understand and accept that if questions arise about administering the medication, the program/camp 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 student’s physician needs to be consulted to assess whether changes to the prescribed medication and/or administrative procedures referred to below 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 below.
  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 director.
  9. This request will terminate at the end of each individual camp enrolment period.
  10. I hereby release, waive, discharge and covenant not to sue the University of Waterloo, its governors, officers, faculty, students, employees, volunteers, independent contractors, agents and representatives or their respective affiliates (collectively, the “Releasees”) from any and all liability to the Participant, me, or my or the Participant’s heirs and next of kin for any and all claims, demands, losses or damages on account of injury, including permanent disability or death (collectively, “Medical Claims”) caused or alleged to be caused in whole or in part by the Releasees’ negligence, breach of any duty of care, including any statutory duty, breach of contract, or any other act of the Releasees as a result of or in connection with, the administration or failure to administer medication as prescribed above. I agree to hold harmless and to indemnify the Releasees from any and all Medical Claims of any third party resulting from the Participant’s participation in the ESQ Camp.
  11. I hereby acknowledge that I have read and fully understand the terms set out herein.
Parent/Guardian Signature(Required)
MM slash DD slash YYYY

COnsent to Use medical information for treatment

  1. As the legal parent/guardian of the above named participant/camper, I understand that all information collected will be used to treat or maintain my child’s physical or mental health and to assist in preventing disease or injury or to promote health. This information is considered to be confidential and will be shared amongst the Senior Outreach team and Camp staff on a need to know basis to ensure the physical and mental health of my child.
  2. To the best of my knowledge, my child is in good health. I will notify the camp in writing prior to arrival if there is any change in my child’s health, or if they are exposed to any communicable disease within 3 weeks prior to arrival at camp.
  3. In the case of a medical emergency, I understand that every effort will be made to contact parents or guardians. In the event I cannot be reached, I hereby give permission to the physician/nurse selected by the Senior Outreach team to hospitalize, secure proper treatment, order injection, anesthesia or surgery for my child as named above.
  4. I agree to reimburse the camp for any prescriptions or medical expenses incurred for this camper.
  5. I will do a head lice check on my child regularly and within 3 days before arriving at camp. Campers found to have head lice on arrival will not be allowed to enter camp until the matter has been resolved. There will be no refund of camp fees.
  6. I will submit any changes to this health form in writing to the camp prior to arrival.
Parent/Guardian Signature(Required)
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.