Participant Information 2026 | Teamworks Dufferin

Participant First Name

Participant Last Name

Caregiver Email

Caregiver Phone

Participant Birthday

Year

Month

Day

Address

Emergency Contact

Emergency Phone

In case of medical emergency I give permission to Zachary's Camp to secure treatment through Emergency Medical Staff. All efforts will be made to contact caregiver or emergency contact

YES

NO

Doctor's Name and Phone Number

Health Card Number

Participant's Diagnosis

Recent Illness

Allergies

Medication

YES (requires separate form)

NO medication needed

Has the participant ever had or currently has seizures?

Assistive Devices:glasses, hearing aid, communication devices

Toileting & Feminine Hygiene

Independent

Needs assistance

Dressing

Independent

Assistance

Swimming

confident swimmer-deep end

confident in the water-shallow end and able to touch ground

Swim Vest-at the beach we requiere vests for everybody if waves are present

Scared of water

Zachary's Camp would like the oppurtunity to post pictures taken during 20025/2026. No Names or exact locations will be posted

I DENY permission to use participants picture at all

I GRANT permission for UNRESTRICTED USAGE of all participants' pictures

Limited permission

Is there any information we should have in order to safely support the participant?