Family Camp Medical Authorization

• To the best of my knowledge, this Health Information Form is correct, all medical problems or conditions have been fully noted, and the camper herein described has permission to engage in all camp activities, except as noted.
• I acknowledge that Luther Village staff and the CHS-MC nurse volunteer called upon to provide medical treatment to my child will be relying on the information contained herein concerning my child’s medical condition.
• I hereby agree to notify the CHS-MC office if there is any change in the health of the camper between the time of completion of this Health information Form and the first day of Camp.
• I hereby give permission for this health information to be shared with the appropriate camp staff, the CHS-MC nurse volunteer and outside medical personnel as necessary.
• I hereby give permission to allow the camper’s Hematologist to release to Luther Village, CHS-MC and the CHS-MC nurse volunteer any medical or other pertinent information about my child on this form. (Forwarding the form to the Manitoba Bleeding Disorders program is notice of your authorization to the Hematologist).
• I hereby give consent and permission for the camper to receive treatment in the camp by the CHS-MC nurse volunteer.
• I hereby give consent and permission for the camper to be evaluated and treated by the CHS-MC nurse volunteer with the advice of the Manitoba Bleeding Disorder Program or the Hematologist on call.
• In the event of an emergency, permission is hereby given to the CHS-MC nurse volunteer to take whatever steps deemed necessary to ensure the safety and health of the camper.

• I give the Manitoba Bleeding Disorders Program permission to release information about my child to CHS-MC and/or the Family Camp nurse volunteer if needed.