ASEF Medical Information & Informed Consent

Please complete this form prior to the first day of the program. This information helps ensure your child's safety and participation. This form must be filled out by the legal parent or guardian.

Step 1: Emergency Contact Information

Relationship

First name *

Last name *

Email *

Mobile *

Step 2: Participant / Child Info

Please enter the participant's/child's information below. A separate form must be completed for each participant. If you are completing forms for multiple participants, please submit a separate form for each individual.

First name *

Last name *

Gender Please specify

Date of birth *

STEP 3: Medical Information, Water Activities & Emergency Care

Medical Information

Does the participant have any medical needs, allergies, or accessibility requirements we should be aware of?

Please provide details regarding:

Medication

If your child carries or uses medication (for example, an asthma inhaler, epinephrine auto-injector, or other medication), please indicate:

What the medication is for
Where it will be stored (with the participant, with staff, or in another designated location)
Any instructions staff should know

Does the participant have any medical needs, allergies, or accessibility requirements we should be aware of?

Allergies & Dietary Restrictions

Please list any allergies, sensitivities, or dietary restrictions.

If dietary restrictions are related to an allergy, please describe the allergy and any accommodations required.

Please list any allergies, sensitivities, or dietary restrictions.

Other Important Information

Please include any information that may assist ASEF staff in supporting your child, including:

Accessibility requirements
Medical alert bracelets
Emergency procedures
Behavioural considerations
Other relevant health or safety information

Please include any information that may assist ASEF staff in supporting your child, including:

Epinephrine Auto-Injector (EpiPen) Does the participant carry an EpiPen? *

Yes No x Clear

If Yes, please specify

Medical Attention Authorization

I acknowledge and agree that:

ASEF staff and volunteers may provide basic first aid when appropriate.
ASEF staff and volunteers may seek emergency medical treatment for my child if I cannot be reached and immediate care is deemed necessary.
I understand that ASEF staff are not medical professionals and are not responsible for medical decisions made in emergency situations by emergency responders, healthcare professionals, or hospitals.
I accept responsibility for all medical expenses that may arise from treatment provided to my child.

I have read and agree to the Medical Attention Authorization. *

Please read and scroll to the bottom to accept.

Water Activity Disclosure

Water Activity Disclosure *

Certain ASEF programs may include water-based activities such as swimming in pools, lakes, oceans, rivers, splash parks, hot tubs, or other aquatic environments.

I acknowledge and understand that:

Water activities carry inherent risks, including but not limited to slips, falls, drowning, injury, illness, changing water conditions, and environmental hazards.
Certified lifeguards may not always be present during water activities.
ASEF staff will implement reasonable safety procedures and supervision practices.
Despite safety precautions, risks cannot be completely eliminated.

I consent to my child's participation in water activities and assume the associated risks. I do NOT consent to my child's participation in water activities. x Clear

Step 4: Electronic signature*

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Step 4: Electronic signature Signature pad

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