Camper Application

Please Note: Campers/Families will be required to attend the Camp Keaton Meet & Greet evening event on Tuesday, May 21, 2019.

Please complete Surname
Please complete First Name
Please complete
Please complete Date of Birth (mm/dd/yy)
Please complete Age on Camp Day
Please complete Grade (June 2019)
Please complete Permanent Address
Please complete City
Please complete Postal Code
Please complete Parent/Guardian Name(s)
Please complete Relation to Camper
Please complete Parent/Guardian Primary Ph. #
Please complete Parent/Guardian E-mail
Please complete Primary Emergency Contact (please include phone # and relation to Camper)
Please complete Secondary Emergency Contact (please include phone # and relation to Camper)
Has your child ever attended camp before?
T-Shirt Size


Please complete T-Shirt Size
Please complete OHIP
Please complete Family Physician
Please complete Phone Number
Dietary Restrictions
Please complete Dietary Restrictions
Allergies
Please complete Allergies
EpiPen required
Please complete EpiPen required
Camper carries own EpiPen
Please complete Camper carries own EpiPen

If your child requires an EpiPen, you must send him/her to camp with one that is within the expiry date.

Immunization: Please give the date of the last immunization shot (mm/dd/yy):

Please complete Diphtheria
Please complete Measles
Please complete Polio
Please complete Pertussis
Please complete Tetanus
Indicate the medical issues for which the camper has been treated:
Please complete Indicate the medical issues for which the camper has been treated:

Agreement

To the best of my knowledge, is in good health, free of communicable disease, and physically able to participate in all the activities, except as noted above. In case of medical and/or surgical emergency, and in the event that I cannot be contacted, I hereby give full authorization to the physician, staff and or nurse selected by the camp director, to secure proper treatment (i.e., hospitalization, injections, transfusions, anesthesia or surgery as appropriately required) for the person as named above. I further authorize Camp Keaton and its agents to disclose any and all information that they deem appropriate and as necessary to secure appropriate care for my child. I agree that I am responsible for any such care rendered to my child and will indemnify and hold harmless Camp Keaton, the Dr. Bob Kemp Hospice and all of their respective affiliated entities, members, agents, service providers, volunteers, employees, medical staff, officers, and directors for such care or related costs or expenses. I certify that the above information is accurate, and that I concur with the statements as described. I understand that by not providing my camp's personal immunization information I may be asked to make the necessary arrangements to pick him/her up from Camp Keaton and Camp Wenonah should a breakout of a communicable disease occur in order to protect myself and other campers.

Please complete

Consent to contact during and after service

Bereavement History

Please include as many details as possible when answering the following questions. We understand that answering some of these questions might be difficult; however, we want to be able to provide the best possible care for your child/teen.

Child/teen's Name:

Please check if either of the following statements are true
How would you describe your family’s communication style regarding the death?

Reaction to the Loss

Please place a check mark next to any of the following your child/teen has exhibited since the death of the loved one:

Other Important Information

Please note that staff uses their utmost discretion in determining when contact by e-mail is appropriate and do not use e-mail to communicate regarding medical, counselling or family care issues.

Photo Posting Policy

We would like to remind you that photographs or video clips taken by Camp Keaton are considered Camp Keaton property. Parents and/or caregivers who have given consent for their children/teenager’s photographs to be distributed have done so ONLY for Camp Keaton Management. Campers, volunteers and staff cannot post Camp Keaton pictures on personal web pages, social media (i.e. Facebook, Instagram) or on public photo sharing websites (i.e. Kodak Gallery, Shutterfly or Caring Bridge) without written permission from Camp Keaton.

If photos or videos are found to be displayed on the Internet, in any capacity, without prior permission of Camp Keaton, the person responsible will be contacted immediately to remove the media content. Thank you for your understanding and cooperation in regards to this matter.

Please complete