Camp Torolago

Torolago Head Office 1853A Avenue Road, Suite 3 Toronto,
Ontario M5M 3Z4 Tel. 416.849.5885 Fax. 416.849.5887
E-Mail. info@torolago.com

Must be completed by Parent, Guardian or Physician.
Thank you for your co-operation.

PERSONAL CAMPER INFORMATION (please print clearly)

Phone Number

Weight

Height

Date of Last Check-up

1. Has your camper had the following: (please check)

If you have circled any of the above ailments please provide the date(s) of occurrence(s) and any
prevelant additional information.

2. Has your camper been immunized against the following; (please check)
	Polio	Recent Booster Date:	Pertussiss	Recent Booster Date:
	Diaptheria	Recent Booster Date:	Tetnus	Recent Booster Date:
	MMR	Recent Booster Date:

3. Is your camper prone to an upset stomach?	Yes	No
4. Is your camper prone to repertory infections?	Yes	No
5. Has your camper ever had a seizure?	Yes	No

If you answered yes to any of the aforementioned questions, please provide us with further details.

6. Does your camper have any allergies?		Yes		No
7. Does your camper have an epi-pen?		Yes		No

If you answered Yes to either or both question 6 and 7, please provide us with the type of allergy,
allergic reaction and treatment.

8.Has your camper ever been clinically depressed?

Yes

If you answered Yes to question 8, please provide us with some further details.

9. Is your camper currently taking any scheduled medication? Yes No

If yes, please list below:

Type of Medication	Dosage	Time	Routine




Please note: that in order for the camp nurse to administer any medication during the camper’s stay at Torolago, the original container with prescribed instructions must accompany the medication. To the best of my knowledge my camper is in good health and is physically able to participate in all camp activities. I will notify Torolago if there is any change in the medical history of my camper between the time of completing this medical history form and their arrival to camp.
			Date