Community of Christ: Canada West Mission

Medical Information Form

(Required for Youth Events only)
Complete a Separate Form for Each Family Member

* Denotes a required field

This medical information is required to help ensure your health and safety while participating in the camp, retreat, or activity for which you are registering. The information is confidential and will be held in strict confidence. It will be shared only with qualified first aid or medical personnel if required. It will be retained for up to twelve (12) months and then destroyed. If you have questions about the collection or use of this information, please contact the Canada West Mission Centre Privacy Officer, Debra Donohue at 1-877-411-2632, ext. 4, or

Note: If you are travelling out-of-province, additional health insurance may be required.

Mental Health

Mental health concerns include any significant events over the last six months which may include hospitalization, suicide attempts, self-harm or psychiatric care. At youth events, staff take any threats or acts of suicide or self-harm very seriously. If these become an issue for your child, parents/guardians will be contacted by camp staff and, if necessary, your child will be taken to the nearest, appropriate medical facility. Briefly describe any mental health concerns at the bottom of this form. (note: medical staff will personally discuss these concerns with you)

Permission for medical treatment

By submitting this form, I understand you will make best efforts to contact the parent/guardian or emergency contact but in the event of an emergency or you are not able to make contact, I hereby authorize any necessary medical treatment the above-named (if parent/guardian). I also guarantee payment of all charges incurred during this medical treatment (physician, hospital, x-ray, lab, medicines, ambulance, other).

Detailed Medical Information

Version: 1.01 (2015-04-23)