Health Permission Form 2012

							                     Gorsebrook Junior High School
                           5966 South Street
                          Halifax, NS B3H 1S6
                             FAX: 421-2709
   principal                       Vice principal                Guidance Counselor
 Agnes Greer                      Maria Rouvalis                Julie Mireault Wiseman
(902) 421-8010                    (902) 421-6673                     (902) 421-2690



                   Duke of Edinburgh
            Adventure Journey - May 5-6th, 2012
                         Health and Permission Form
                                                                               st
     THIS FORM MUST BE COMPLETED & RETURNED TO MS MERCER BY MAY 1 .


NAME: __________________________________________________

HEALTH CARD #: _______________________ EXPIRY: __________

N CASE OF EMERGENCY, PLEASE NOTIFY:
      1.
      NAME: ________________________________________
      PHONE: __________________ (h) __________________ (c)
      2.
      NAME: ________________________________________
      PHONE: __________________ (h) __________________ (c)

FAMILY DOCTOR: _____________________________________

HAS YOUR CHILD EVER SUFFERED FROM ANY OF THE FOLLOWING?
Asthma, Epilepsy, Hay Fever, Rheumatic Fever, Diabetes, Bed Wetting, Sight, Hearing
or Speech Impairment, Motion Sickness, Physical Limitations or Disabilities, Insomnia
IF YES TO ANY OF THE ABOVE, PLEASE INDICATE THE SYMPTOMS AND MEDICAL
TREATMENT IF REQUIRED:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

DESCRIBE ANY OTHER HEALTH PROBLEM(S) FROM WHICH YOUR CHILD SUFFERS AND
ANY MEDICAL TREATMENT THAT IS REQUIRED:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

DOES YOUR CHILD HAVE ANY ALLERGIES? YES NO
IF YES, PLEASE SPECIFY: PLANTS, FOOD TYPES, INSECTS, DRUGS, ETC.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
IS YOUR CHILD ON ANY FORM OF REGULAR MEDICATION? YES NO
IF YES, PLEASE SPECIFY WHETHER YOUR CHILD WILL NEED MEDICATION AT THE
CAMP, WHAT TYPE, HOW OFTEN, AND HOW MUCH?
_____________________________________________________________________________
_____________________________________________________________________________
______________________________________

IS YOUR CHILD ON A SPECIAL DIET? YES ___ NO ___
IF YES, PLEASE DESCRIBE IN DETAIL:
________________________________________________________________
________________________________________________________________
________________________________________________________________

PLEASE LIST ALL SIGNIFICANT ILLNESSES OR DIFFICULTIES WITHIN THE LAST YEAR
_____________________________________________________________________________
___________________________________________________
________________________________________________________________

IS THERE ANY ACTIVITY IN WHICH YOUR CHILD SHOULD NOT PARTICIPATE? PLEASE
EXPLAIN.
________________________________________________________________
_____________________________________________________________________________
___________________________________________________


I hereby declare that all of the information provided is correct and accurate to the best of my
knowledge. I give permission for my child to participate on the Duke of Edinburgh Adventure Hike
lead by Ms Mercer & Ms Scott. I hereby recognize that although safety will be considered of
utmost importance, that outdoor activity, by its nature, involves elements of risk. In the event of an
emergency, I give permission for my child to receive appropriate first aid by staff certified in
standard first aid training, and appropriate treatment by licensed health professionals.


_______________________________                   _____________________
Signature of Parent/ Guardian                    Date