HEAD SHOT HERE - hemophilia.ca · Poison Ivy ☐ Insect Bites ☐ Peanuts ☐ Penicillin ☐ Animals ☐ Food ☐ Drugs ☐ Other ☐ _ _ _ _ 3. Epipen or Anakit Does he/she have

PARTICIPANT’S FILE

(Please fill out the form and return it to us with your registration)

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1. GENERAL INFORMATION (Please fill out one form per registered child)

GLUE A

HEAD

SHOT

HERE

(Mandatory)

*Add as an attachment

if registering by email

Is this his/her first camp experience? Yes ☐ No ☐

If not, how many times:

Type of camp (CHSQ, regular, etc.):

Does your child have siblings? Yes ☐ No ☐

Will they be present at the camp? Yes ☐ No ☐

Does your child enjoy being in a group? Yes ☐ No ☐

What are his/her favourite meals:

Does your child have dietary restrictions or special food preferences? If yes, please

specify.

In what school grade will your child be registered in September 2019?

Does your child know how to swim? Yes ☐ No ☐

What is your child’s attitude when playing? Cooperative ☐ Competitive ☐

Specify:

If your child is slightly frustrated, how does he/she react? He/she talks about it ☐

He/she withdraws ☐

Other, specify:

Does your child get angry easily? Yes ☐ No ☐

Is your child incontinent? Yes ☐ No ☐

If yes, do we need to wake him or her up at midnight to go pee? Yes ☐ No ☐

(Girls only) Has she had her period? Yes ☐ No ☐

If not, is she prepared for it? Yes ☐ No ☐

Child’s T-shirt size:

M ☐ F ☐ Gender: DD / MM / YY

Date of Birth

Surname: First name:

/ /



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The camp leader would like to get to know your child before his/her arrival. Please write a few words describing your child, including ways to reach out to him/her:

Other important things to know about your child:

Has your child experienced a trying situation lately (accident, death, etc.)? Yes ☐ No ☐

If yes, what special support do we need to offer?

* Please ensure at least one person is reachable at all times

Relationship:

Relationship: Name:

Phone:

Name:

Phone:

Contact information of two other individuals to reach in case of emergency (mandatory)*

Telephone number to reach parents/guardian while at camp*:

Father’s Name: Phone:

Cell Phone: Work:

Mother’s Name: Phone:

Cell Phone: Work:



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2. CHILD’S MEDICAL RECORD (fill out for each child)

If your child suffers from a coagulation disorder, make sure you also fill out Section

3. We will follow up one week before the start of camp to update the medical

information as needed.

1. Medical History

Has he/she ever had:

Ear infections ☐

Mumps ☐

Chicken Pox ☐

Measles ☐

Scarlet Fever ☐

Has he/she been vaccinated for:

Measles ☐

Rubella ☐

DTP ☐

Polio ☐

Meningococcal

disease ☐

Does he/she suffer from:

Hernia ☐

Diabetes ☐

Asthma ☐

Other ☐

2. Allergies Yes ☐ No ☐ If no, go to Section 4

Hay Fever ☐

Poison Ivy ☐

Insect Bites ☐

Peanuts ☐

Penicillin ☐

Animals ☐

Food ☐

Drugs ☐

Other ☐

_

_

_

_

3. Epipen or Anakit

Does he/she have an adrenalin dose? ☐

Administered by the child? ☐

Administered by another person? ☐

Name:

I hereby authorize the persons designated by the CHSQ and Camp Trois-Saumons to administer, as needed or in case of emergency, a dose of adrenalin to my child.

Signature of parent/guardian

4. Surgery

Health Insurance Number Expires: / MM / YY

DD / MM / YY Weight: (Specify kg or lbs) Date of Birth

M ☐ F ☐ Gender: / /

Surname: First name:

Has your child ever had surgery? ☐ Date of surgery

Type of surgery and outcome:



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5. Serious Injuries

6. Medication

7. Authorization to take medication at camp

I authorize care providers to administer one or more of the following medications to my child as needed:

Acetaminophen (Tylenol, Tempra) ☐

Antiemetic (Gravol) ☐

Antihistamine (Benadryl, Claritin, Allegra) ☐

Cough Syrup ☐

Ibuprofen (Advil) ☐

Antibiotique cream (Polysporin,Neosporin) ☐

Parental Authorization

By signing this, I authorize the CHSQ Summer Camp management to provide my child with all the medical care required in case of emergency. I also authorize the management to bring my child to a hospital or community health clinic by ambulance or other means if it deems this necessary. In addition, if we cannot be reached, I authorize the doctor chosen by camp authorities to provide my child with all the medical care required by his/her condition while at camp, including surgery, anaesthesia and hospitalization.

Signature of parent/guardian Date

Date of serious injuries:

Type of surgery and outcome:

Yes ☐ No ☐ Has your child ever been seriously injured?

If yes, will he/she take it while at camp? Yes ☐ No ☐

Dose and restrictions where applicable:

Yes ☐ No ☐ Does your child take medication regularly?

8. Family Doctor

Name: City:

Clinic/hospital where he/she can be reached:

I hold harmless the Canadian Hemophilia Society - Quebec Chapter (CHSQ) and its staff from

all liabilities incurred following an accident, injury or illness arising while at summer camp:

Signature of parent/guardian Date


(Return before July 16)

0

3. Medical record for a child with a coagulation disorder

1. Allergies

2. Prophylactic treatment / Immune tolerance

3. Treatment of bleeding for children with coagulation antibodies

Diagnostic:

Coagulation clotting factor:

Health Insurance Number Expires: / MM / YY

DD / MM / YY

Date of Birth Weight: (Specify kg or lbs)

M ☐ F ☐ Gender: / /

Name: First name:

If yes, specify:

Yes ☐ No ☐ Allergy to a coagulation product

Product: Product:

Dose: Dose:

Frequency/days: Frequency/days:

Frequency/days: Frequency/days:

OTHER ☐ OTHER ☐

Treatment: Treatment:

Dose: Dose:

FEIBA ☐

Dose:

Frequency/days:

Nia Stase ☐

Dose:

Frequency/ days:



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LIST OF ITEMS FOR TREATING CHILDREN WITH A DISORDER

As mentioned above, an additional bag is required for children with a coagulation disorder.

It must contain all the material required for treating your child:

Other medications needed for other medical conditions must be inside this bag. Medications for

siblings must be in this bag and properly identified with the child’s name.

Nurses will have, among other things, the following in their possession:

Don’t forget that your child is not alone and that everything must be identified.

Thank you for your collaboration!

4. Target Joints

5. Level of independence of the child in treating him/herself

6. Other

Cotton wool or compress

Tourniquet

Bandaids

Alcohol swabs

Winged micro-infusion set (BUTTERFLY)

Personal compression wrap (tubigrip) if used regularly

Sling, personal brace if used regularly

Treatment items with the name of the child for the week, plus one 100% dose in case of emergency

PORT-A-CATH–PiccLine

Alcohol swabs

Bandaids

Virox wipes for

disinfecting work surfaces

Yellow boxes for disposal of materials

White disposable surface wipe for injections

Calendar pages with pencils to note injections and administration of other medications

☐ Independent (prepares his/her concentrate and injects it him/herself)

☐ Semi-independent (prepares his/her concentrate; does not inject it him/herself)

☐ Non-independent; specify his/her routine (disinfects...):

Joints that have experienced major or repeated bleeding in the past. If

yes, which ones:

Habits, special issues or other information about your child that would be useful to

nurses and/or camp leaders:

_



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4. REPLY COUPON FOR TRANSPORTATION

CHSQ Summer Camp at Camp Trois-Saumons,

August 4 to 9, 2019

Surname and first name of children registered at the camp:

Child 1•

Child 2•

Child 3•

Child 4 •

I would like my child to travel in a bus ☐ YES ☐NO

TO THE CAMP: ☐ Departure from Montréal

☐ Departure from Drummondville

☐ Departure from Québec

☐ I will drop my child off myself.

RETURN TRIP: ☐ Stop in Montréal

☐ Stop in Drummondville

☐ Stop in Québec

☐ I will pick up my child myself.

Name of parents:

Date:

Signature:

2 *Stops are determined according to needs and at central locations to meet the needs of the greatest number of campers.



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5. AUTORIZATION FOR TAKING PICTURES

Smile – click-click!

As usual, we would like to take pictures of the children for

publication in the CHSQ’s main communication channels,

including l’Écho du Facteur, websites, Facebook page, annual

report and the CHS’s Hemophilia Today. It’s also a good

opportunity to capture the best moments of this activity and

keep some good memories!

We ask you to fill out the bottom section and send it to us with your camp documents.

Thank you!

I, the undersigned, ,

parent of ,

(Name(s) of child or children)

authorize taking pictures at the CHSQ’s 2019 Summer Camp for

publication in the organization’s communication channels.

do not authorize taking pictures at the CHSQ’s 2019 Summer Camp

Date: Signature:

Documents

HEAD SHOT HERE - hemophilia.ca · Poison Ivy ☐ Insect Bites ☐ Peanuts ☐ Penicillin ☐ Animals ☐ Food ☐ Drugs ☐ Other ☐ _ _ _ _ 3. Epipen or Anakit Does he/she have