Your kit list

Please print - This form is to be completed and must be signed by the participant’s parent or legal guardian if under the age of
18. Please be very specific with all information so that the staff is fully informed. Feel free to include extra explanation sheets.

Legal Name:
DOB: M: D: Y:
Preferred Name:
Pref. Gender ID:
Are you on Facebook? □ Yes □ No If Yes, find us on Facebook: “Anglican Youth Cell #: ( )
Diocese of Niagara – Youth Ministry” and “like” us to see posts and YM updates! Parish (include city/town):
Parent Name:
Parent Name:
Family Physician’s Name:
Alternate Contact:
Health Card #: Relationship to Participant:
Are there any special dietary requirements? □ No □ No: but no red meat □ Vegan □ Yes: but wil eat: chicken □ fish □ eggs □ dairy □ Are al the participant’s vaccines up to date? □ Tylenol □ Advil □ Other (specify):

Are there any adaptations, accommodations or Individualized Education Plans in place that make for a bet er learning
environment for the participant? If so, please describe so we can ensure the best possible learning experience.

□ Reaction to bees, wasps, hornet stings □ Other al ergies: Please describe severity and reactions (e.g. life-threatening, breathing problems) Treatment (e.g. Benadryl, injection; dosage & times given): Needs Epipen® kit: Yes □ No □ Participants must carry their own personal Epipen®.
Name of medication:
Dosage & Frequency:
Reason for use:
Fight off scurvy & nutritional supplement *if more room is required please feel free to attach an additional sheet Other side…
You may attach additional pages if needed
Please provide information in order to expand our ability to care for the participant. Describe any il nesses (e.g.
Epilepsy, Fainting Spel s, Migraine/Headaches, etc.) or conditions that would be important for our staf to know about and how these conditions are dealt with at home. Please share with us any changes at home that might impact her/his participation (e.g. a death, separation or divorce, or any other traumatic experience). i. The parent(s) or guardian(s) submit ing this application are those having legal custody of the participant. Conditions of custody and access, if applicable, should be communicated in writing to the Program Department. ii. I consent to my daughter/son’s participation in the activities associated with the program unless a physician’s note has been writ en to excuse her/him or further information has been noted on the health form. iii. Program Staff reserves the right to dismiss a participant who has displayed unacceptable behaviour, and/or has not complied with the norms of the event, or for medical reasons. iv. The parent(s) or guardian(s) agree to hold harmless the Diocese of Niagara, its employees, and volunteer staff from any cost or liability in connection with the injury, death or damage to any person or property during this event. v. In the case of medical or surgical emergency, I understand every effort wil be made to contact parent(s) or guardian(s). In the event I cannot be reached, I hereby authorize and consent to Diocese of Niagara, its employees, and volunteer staff to obtain medical assistance including first aid, treatments, transport, hospitalization, blood transfusion and/or anaesthesia or surgery if required. I give permission to contact this participant’s personal physician for clarification of medical treatment. vi. I agree to release Diocese of Niagara, its employees, and volunteer staff from any cost or liability arising out of the performance of any medical procedure in relation to such medical assistance. vii. Each participant must be covered by provincial or equivalent health insurance. I hereby assume full responsibility for any extra expenses required for the treatment of the participant that is not covered by Ontario Hospital Insurance or equivalent viii. The Diocese of Niagara reserves the right to use print and digital images and videos of all program participants in our advertising, marketing, websites and through social media UNLESS provided with a writ en document withholding ix. The Diocese of Niagara is commit ed to protecting the confidentiality, privacy and accuracy of personal information it col ects. The information gathered in this form wil be used solely to support the participant’s involvement with the Diocese of Niagara and wil not be disclosed to a third party except in a medical emergency. Signature of Participant
Signature of Parent/Guardian (if under 18 yrs)
Please sign and return this form to:
Jane Wyse, Diocese of Niagara, 252 James St. N., Hamilton, ON L8R 2L3 or 905-527-0963 A.S.A.P.
Event Use Only: Treatment notes to be completed by staf person dispensing meds or first aid


External programme editors' template

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