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Discovery Healthcare Registration Form


Western respects your privacy. The personal information collected on this form is collected under the authority of the University of Western Ontario Act, 1982, as amended, and is used for the purpose of research and evaluation. Please note that no information about you, including your email address, will be disclosed to external third-party organizations without your consent. Your name and contact information can be removed from our database at any time by contacting the Office of Distributed Education by telephone, fax, email or by regular mail.

Please direct questions about this collection, use or disclosure of personal information to Julie Stuifbergen, Discovery Healthcare Coordinator, Distributed Education, by telephone 519-661-2111, extension 22147 or email

Registration Payment Refund and Cancellation Policy 

A 20% non-refundable administration fee is applied to all cancellations made up to 10 business days prior to the participant's start date.

All cancellations must be submitted in writing at least 10 business days prior to the participant's start date. No refunds will be issued for cancellations made less than 10 business days prior to the participant's start date.

Fields denoted by an asterisk (*) are required.

Parent/Guardian Information

Student Information

Please indicate your career interest in a maximum of 50 words
The following five (5) fields must be completed. If any of these do not apply to you, please type “not applicable”.

High School Information

Emergency Contact Information


I/We the undersigned, hereby acknowledge that certain risks of injury are inherent to participation in hands-on camp activities. These types of injuries may be minor or serious and may result from one’s own actions, or the actions of others, or a combination of both. I/We understand that the rules and regulations are designed for the safety and protection of participants and hereby undertake that my child will abide by these rules and regulations. I/We hereby warrant that my/our child is physically fit to participate and understand that the choice to participate brings with it the assumption of those risks and results which are part of these activities. I/We agree that the Governing Council of the University of Western Ontario, their directors, officers, employees, students, and volunteers, shall not be liable for any injury to my child or loss or damage to my child’s personal property arising from, or in any way resulting from, his/her participation in those activities, unless such injury, loss or damage is caused by the sole negligence of the University, their directors, officers, employees, students, and volunteers, while acting within the scope of their duties. I/We agree to allow my child to receive basic first aid/ medical care from instructors certified in first aid or trained medical professionals if necessary. I/We declare having read and understood the above Informed Consent Agreement in its entirety and hereby consent to participate acknowledging all the foregoing. I/We also certify that the information provided in this form is, to my/our knowledge, true and complete.


Discovery Healthcare is dedicated to fostering a safe and welcoming environment that is committed to celebrating all differences among our participants. In order to provide a respectful and inclusive environment, Discovery Healthcare has implemented a Code of Conduct to ensure the well-being of each participant.

As participants at Discovery Healthcare you have the right to feel safe and supported by your fellow participants and program staff. You have the right to be treated with respect, and in return you must treat others with respect. To help ensure all fellow participants are treated with dignity, all participants must follow the Code of Conduct.


  • Follow the camp rules and directions of program staff
  • Participants must show respect for themselves, fellow participants, program staff, and community members. Bullying will NOT be tolerated.
  • Use respectful language (for example, no swearing, racial or offensive comments)
  • Take responsibility for your actions, words and belongings
  • Remain with their group and counsellors when at public and community facilities
  • Talk to a counsellor if they feel unsafe in any way


  • Threaten or intimidate another person
  • Cause injury of any sort or encourage others to inflict harm to any other participant or program staff
  • Trespass, steal, vandalize or cause damage of any sort to the program equipment, community facilities or other participant’s belongings
  • Use foul, abusive or inappropriate language