Nipissing Mini-Lakers PD Day Camp

Participant Details

* Participant's First Name

* Participant's Last Name

* Preferred Name

* Preferred Pronoun

* Age During Camp

* Date of Birth

* Grade (as of September)

Parent/Guardian Details

* Parent/Guardian Name

* Relationship to Participant

* Email

* Cell Phone Number

Work Phone Number

* Address

* Emergency Contact 1 - Name

* Emergency Contact 1 - Cell Phone Number

Emergency Contact 1 - Work Number

* Emergency Contact 2 - Name

* Emergency Contact 2 - Cell Number

Emergency Contact 2 - Work Number

Medical Information

Please review the Medicine at Youth Programs section in the Parent/Guardian Handbook located in our Parent/Guardian Portal and complete the following mandatory fields:

Medicine at Camp Authorization

Please check off and fill out the necessary information if your child will require medication while at camp.

Getting Medicine to Camp

All medication should be transported to the camp by an adult and handed to another adult.
Your child should not carry his or her medication during camp hours. The university camp staff will ensure immediate access to emergency medications.
Only trained camp staff may be involved in medication administration.
All medication must be brought to camp in the original labeled container prepared by the pharmacy, doctor, or pharmaceutical company (i.e., no envelopes, foil, or baggies).
All prescription and non-prescription medication (including vitamins) given in camp settings require written authorization from your child's doctor, as well as parent written consent.
Your child's doctor must include the following instructions with the medication:
- Date of order
- Name of child
- Reason for medication
- Name of medication to be administered
- Dosage
- Time of administration
- Route of administration
- Length of time the medication needs to be given
- Possible side effects
- Special requirements such as "take with food"
- Whether or not medication may be self-administered
Camp staff is not authorized to determine when an "as needed" medication is to be given. Specific instructions are necessary (e.g., every 4 hours, as needed for headache). For children with chronic health conditions, this can be determined in collaboration with the consulting nurse.

* Name of Doctor

* Doctor's Phone Number

* Name of Medication

* Dose/Time Required

* Details of Medication (e.g., What is the epiPen for? Does the medicine need to be taken with food? etc.)

* Possible Side Effects

Additional Information Youth Program Staff should be made aware of

* Parent/Guardian Portal

All parents/guardians must visit the Portal and read all information provided carefully including the Informed Consent and Handbook in their entirety. Click Here

I understand and acknowledge that by checking this box I waive all legal rights, including the right to sue or claim compensation following any incident or accident and confirm that I have read the Informed Consent and Parent/Guardian Handbook entirely. I understand that I may request a copy of these documents by emailing the Office of Extended Learning at [email protected]

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Mini-Lakers PD Day Camp - March 7, 2025

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