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Participant's Name (required)
Parent's Email (required)
Participant's Date of Birth (required)
Gender: Male Female
Health Card #:
Will the participant be carrying or requiring any medication to be taken/administered at lessons/camp?
Does this participant have any health or behavioral conditions we should know about (allergy information to be listed below)?
You are required to fill out this section if your child has a known or suspected allergy and is at risk for allergic complications and/or anaphylaxis.
This child has a dangerous Life-threatening allergy to the following substances:
This child will react to the above listed substances upon:
Inhalation Contact Ingestion
Please list any detailed information about your child's allergy:
Symptoms (known) specific to your child (0 – 15 minutes after consumption or contact):
Any other medication to be given, with specific instructions:
Does the Participant require an EPI-PEN? Yes No
2nd EPI-PEN carried? Yes No
In the event of an emergency, I give permission for a Staff Member trained in Emergency procedures and First Aid to assist my child in administering their personal EpiPen.