Medical Information and Consent

Please complete a separate form for each child.

Child/Youth Information

First name *

Last name *

Date of birth *

Address: *

Health Card # *

Does your child need personal care products (i.e. tampons, pads, etc.)?

Does your child have any allergies? *

Yes No

What are their allergies?

Nuts Peanuts Eggs Insect bites/stings Seafood

Other

Do they have Anaphylaxis? *

Yes No

Epinephrine Auto-Injector information:

Expiry Date: *

Dosage: *

EpiPen Jr 0.15mg EpiPen 0.3mg ALLERJECT 0.15mg ALLERJECT 0.3mg Emerade 0.3mg Emerade 0.5mg

Other (please specify):

Location of Auto-Injector(s): *

Have they had a previous anaphylactic reaction? *

Yes No

If they have please describe:

Signature

The undersigned parent or guardian authorizes any responsible adult to administer epinephrine to the child named above in the event of an anaphylactic reaction. The protocol has been recommended by the child's physician.

Does your child have any dietary restrictions? *

Yes No

What are the dietary restrictions?

Does your child have any medical conditions?

Asthma Diabetes Epilepsy Other (enter below)

What is the condition?

Do they carry a puffer? *

Yes No

Medications

Medication

Dosage

Frequency

Parent/Guardian

Already have an account?

Connect

You will receive an email confirmation and a copy of this form once it has been submitted.

Relationship

First name *

Last name *

Email *

Mobile

Is your address the same as the child's? *

Yes No

What is your address?

Emergency Contact Information

Please provide contact details of an individual who can be reached in case of an emergency

Relationship

First name *

Last name *

Email *

Mobile

Can pickup child

Is there any additional information we should be aware of?

This information is confidential and will only be shared with staff and health care personnel as needed to ensure a safe and enjoyable experience for all participants. A copy will be securely stored internally, and a copy will be available on site.

In the event your child requires urgent medical attention (e.g. anaphylactic reaction, potential concussion, anticipated break of bone), it is our policy to notify you as soon as possible. If we are unable to reach you or your designated emergency contacts, and immediate medical attention is required, we will call Emergency Services (911) without delay.

I have read and agree to the above. *

By signing this form, I authorize YFNED staff to take appropriate action on my child’s behalf in the event of illness or injury. This includes administering first aid, prescribed medication as noted above, and general over-the-counter medication such as allergy relief (e.g., Benadryl), acetaminophen (e.g., Tylenol), ibuprofen (e.g., Advil), and antacids. I also consent to YFNED staff sharing this information with medical professionals if my child requires emergency medical care.

Parent/Guardian Signature*

Please sign your name in the box below.