ZWIAZEK HARCERSTWA POLSKIEGO Polish Scouting Association

ZWIAZEK HARCERSTWA POLSKIEGO Polish Scouting Association

ZWIAZEKHARCERSTWAPOLSKIEGO
PolishScoutingAssociationinCanada
PermissionForm/Pozwolenie
HufiecMłodyBór–OBÓZ2016
Participant’sName:_____________________________________________Stopień:_________Szczep_______________
DateofBirth(M/D/Y):_____________________________HealthCardNumber__________________________________
Participant’sHomeAddress:____________________________________________________________________________
City:__________________Province:______PostalCode:________________HomePhone:________________________
Parent(s)/GuardianNames:_____________________________________________________________________________
Mother’sWork/MobilePhone:______________________Father’sWork/MobilePhone:__________________________
ContactE-mailaddress:________________________________________________________________________________
EmergencyContactName:__________________________________EmergencyContactNumber:__________________
(otherthanparent(s)/guardianlistedabove)
Relationshiptoparticipant:_______________________________________________
PERMISSION/POZWOLENIE
Igivepermissionfor______________________________________________totakepartintheSummerCamp(ObózHarcerski)
(participant’sName&Surname)
takingplaceatStanicaKopernik–GarnerLake,AlbertafromJuly3toJuly16,2016.
Thecampprogramincludesthefollowingactivities:walkingandhiking,swimming,canoeing,singing,crafts,outdoorsportsand
activities,andgames.
Permissionisgiventotakepartinallactivities,exceptfor:____________________________________________________________
IreleaseandagreetoindemnifyandholdharmlessthePolishScoutingAssociation,itsunits,membersandvolunteersfromany
liabilityconcerningmyParticipantchild’sinvolvementinapprovedscoutingactivities.
Iunderstandthatphotographsmaybetakenduringthisscoutingactivitybytheorganizers,andtheresultingimagesmaybeusedin
theAssociation’sbrochuresandpromotionalmaterialsincludingtheAssociation’swebsites,withoutfurthernoticetome,andI
consenttosuchuseofthephotos.
Iunderstandthat,intheeventmychildissenthomeduetoaviolationofthestandardsofconduct,Iwillbearallcostsofthe
transporthomeandIacknowledgethatIwillreceivenoreimbursementofscoutingoractivityfees.
Parent’s/Guardian’ssignature:_____________________________________Date:___________________
Parent’s/Guardian’sname(pleaseprint):________________________________
**********************************************************************************************************
Bysigningbelow,Iagreetoabidebyallrules,regulationsandproceduresandstandardsofconductasprescribedbythePolish
ScoutingAssociationanditsunits.
Participant’ssignature:__________________________________________Date:________________
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PARTICIPANT’SNAME:_____________________________________________EVENT&DATE:ObόzHarcerski,July3-16,2016
ALLERGIES/ASTHMA
Listanyallergiessuchasfood,insectstings,drugs,etc.Clearlyexplainallergyand/orasthmasymptoms.Ifreactionissevere,please
makecertainthattheseverityofthereactionisclearlyindicatedandwhethertheparticipantcarriesanEpiPen.Ifmorespaceis
requiredtoexplainthemedicalconcern,pleaseattachtheexplanationonaseparatepieceofpaper.
Allergy/Asthma
RateSeverity
mildsevere
12345
12345
SpecificTypeofReaction
UsualTreatment
DIETARYRESTRICTIONS
Listanyfoodstheparticipantshouldnoteatformedicalreasons.Iffoodsarelifethreatening,explainthesymptomsandindicateif
theparticipantcarriesanEpiPenforthispurpose.
MEDICALCONDITIONS
Pleasecheckoffanylifethreateningconditions,physicallimitationsoranyotherconcernswhichmightaffectparticipationinthe
program.
Epilepsy
yes
no
FaintingSpells
yes
no
Diabetes
yes
no
DigestiveUpsets
yes
no
MigraineHeadaches
yes
no
Sleepwalking
yes
no
BleedingDisorder
yes
no
ChronicEar,Nose,ThroatInfections
yes
no
UrinaryInfections
yes
no
Nosebleeds
yes
no
MedicAlertInformation
yes
no
BedWetting(ifyes,pleasesupplyDepends)
yes
no
MedicAlertFor:
Other
Detailsforusualtreatment:
MEDICATION(informationfordayorovernighttrips)
Themedicationbeingcarriedbytheparticipantwillbemonitoredbyacounsellororregisteredmedicalstaff:
NameofMedication
Dosage
MethodofAdministration
Reason
Self*Medicating?
*Selfindicatestheparticipantisinpossessionofthemedication.
Ifnecessary,mayoverthecountermedicationsbeadministeredininstancesoffever,coldand/orminordiscomfort(i.eTylenol,
Motrin,Benadryl,coldsyrup,etc.)?YESNO
HastheparticipantreceivedaTetanusshotwithinthelast10yrs?YESNO
DateoflastTetanusshot
CONSENT/POZWOLENIEREGARDING(PARTICIPANT’SNAME):___________________________________________________
Intheeventthatmedicalcareisrequired,Iunderstandthateveryeffortwillbemadetocontactme.Iacknowledgethatinthecaseofanemergency,medical
treatmentmaybesoughtbyanInstructorand/orprovidedbyhealthcarepractitionerswithoutmyconsent.IherebyauthorizetheScoutingInstructorsto
securesuchmedicaladviceandservicesasmayberequiredforthehealthandsafetyofmyselformychild(orward).Iagreetoacceptfinancialresponsibility
inexcessofthebenefitsallowedbymyProvincialHealthPlanandtoreimburseregisteredcampstaffformedicalprescriptionspurchasedformychild.
Wwypadkupotrzebyuzyskaniaopiekimedycznej,rozumiemzeInstruktorzy/Druzynowiprowadzacyzajeciadolozawszelkichmozliwychstaranbysiezemna
skontaktowac.Rozumiemzewsytuacjachnaglychinterwencjamedycznamozenastapicbezmojegopozwolenia.Upowazniamosobyprowadzaceharcerskie
zajeciadozasiegnieciapotrzebnejopiekimedycznejdlazapewnieniazdrowiaibezpieczenstwamojegolubmojegodziecka(czymojegopodopiecznego).
Przyjmujeodpowiedzialnoscfinansowazakosztyniepokryteprzezrzadowyplanzdrowiałączniezlekaminareceptęzakupionymidlamojegodziecka.
SignatureofParent/Guardian(orparticipantifover18yearsofage)
Note:Thesignatureofaphysicianisonlyrequiredforaparticipantwithalifethreateningmedicalcondition.
Date
Physician’sName: SignatureofPhysician:
Physician’sTelephoneNumber:
Date:
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