CAMP ROMUVA 60 - HEALTH FORM
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THIS INFORMATION IS CONFIDENTIAL AND IMPORTANT TO THE HEALTH AND SAFETY OF ALL PARTICIPANTS
NOTE:  This form is to be filled out by the parent/guardian at the beginning of each Scouting year and kept by the leader or registrar.  It is the responsibility of the parent/guardian to update the leader or registrar of any changes in the medical condition of their child/ward throughout the Scouting year.  This form must also be completed for adult leaders and volunteers.
LAST NAME *
FIRST NAME *
DATE OF BIRTH *
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AGE *
GENDER *
GROUP *
HOME ADDRESS *
CITY *
PROVINCE / STATE *
POSTAL CODE / ZIP CODE *
HOME PHONE NUMBER
CELL PHONE NUMBER
PHYSICIAN'S NAME *
PHYSICIAN'S PHONE NUMBER *
OHIP NUMBER (Provincial Medical Plan - if from outside Canada indicate N/A) *
OTHER INSURANCE COVERAGE
INSURANCE COMPANY NAME AND POLICY NUMBER
EMERGENCY CONTACT NAME *
EMERGENCY CONTACT PHONE NUMBER *
EMERGENCY MEDICAL INFORMATION
INCOMPLETE INFORMATION MAY RESULT IN THE APPLICANT BEING SENT HOME AT THE FAMILY'S EXPENSE
DOES THE APPLICANT HAVE ANY ALLERGIES? *
ALLERGIES
ALLERGIES - PLEASE EXPLAIN IN FURTHER DETAIL
THE APPLICANT HAS HAD (PLEASE CHECK ALL THAT APPLY)
OTHER CONDITION - ADDITIONAL INFORMATION
IS THE APPLICANT SUBJECT TO ANY OF THE FOLLOWING
(PLEASE CHECK AND PROVIDE DETAILS AND COPING METHODS, IF APPLICABLE)
ADDITIONAL INFORMATION
DATE OF MOST RECENT PHYSICAL EXAMINATION *
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DATE OF LAST TETANUS SHOT *
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BY CHECKING THE BOX BELOW, I CONFIRM THAT I AM FULLY VACCINATED AGAINST COVID-19 AND WILL EMAIL THE VACCINATION RECORD TO TORONTOTUNTAI@GMAIL.COM IF NOT ALREADY ON FILE.                                                                                                                                                                                        (VACCINATION REQUIREMENT DOES NOT APPLY TO CHILDREN UNDER THE AGE OF 12.  PLEASE CHECK THE BOX IF THIS REGISTRATION IS FOR A CHILD UNDER THE AGE OF 12)                                                                                                                                                                                                                                                                     I UNDERSTAND MY REGISTRATION WILL NOT BE CONSIDERED COMPLETE AND WILL NOT BE ABLE TO PARTICIPATE IN ANY IN-PERSON ACTIVITIES UNTIL RECEIVED AND CONFIRMED BY TORONTO TUNTAI. *
Required
IF FEMALE, HAS YOUTH MENSTRUATED?
Clear selection
IF NO, HAS SHE HAD MENSTRUATION EXPLAINED TO HER?
Clear selection
DOES THE APPLICANT REQUIRE SPECIAL CARE, MEDICATION or DIET? *
IF YES, PLEASE EXPLAIN IN DETAIL BELOW
HAS IT BEEN NECESSARY TO RESTRICT THE APPLICANT'S ACTIVITIES FOR MEDICAL REASONS? *
IF YES, PLEASE EXPLAIN IN DETAIL BELOW
SWIMMING ABILITIES *
SWIMMING ABILITIES - HIGHEST LEVEL ATTAINED
PARENT/GUARDIAN/VOLUNTEER/LEADER SIGNATURE - TYPE YOUR FULL NAME *
DATE SIGNED *
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