Child’s Emergency Medical Authorization

Medical and Insurance Information:

Your child’s participation in the 2015 Kent Gardens PTA Summer Camp requires this form to be completed IN FULLfor all students and turned in to the office no later than the first day of camp. This information will be held in the school office and will only be shared with the administration and teachers that are directly working with your child. One form per child is sufficient for children attending more than one class.

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Child’s First Name Child’s Last Name Date of Birth (mm/dd/yy)

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Parent/ Guardian Name Contact Phone number

  1. Medical costs for my child are covered by:
  2. Insurance Company ______
  3. Policy Number ______
  4. Phone Number ______
  1. I am not providing medical insurance information and will be responsible for payment of medical expenses if incurred for my child during summer camp 2013 hours ______

initials

Date of last immunization: The PTA cannot access your child’s records from school files. Please, provide month and year of last immunization:

MMR: ______Hep: ______

Polio: ______Chicken Pox: ______

The parent/guardian of ______authorizes the school to obtain immediate medical care and to be transported to the emergency room and consents to the hospitalization of, the performance of necessary diagnostic test upon, the use of surgery on, and/or the administration of drugs to his/her child or ward if an emergency occurs when he/she cannot be located immediately. It is understood that this agreement covers only those situations which are true emergencies and only when he/she cannot be reached. Otherwise he/she expects to be notified immediately.______

Initials

I authorize the school to take my child to participate in the summer program within the school building, its grounds and the adjacent Kent Gardens Park. Any other trips off the premises will be individually requested.______

Initials

1. Does your child has any allergies or is allergic to anything?

NO YES If yes please specify:______

2. Does your child need an EPI Pen or an Inhaler on site? (if yes, you must complete the dedicated forms)

NO YES If yes please specify:______

3. Are there any dietary considerations that we should know?

NO YES If yes please specify:______

3. Does your child have any special needs that we should know about?

NO YES If yes please specify:______

4. Is there any information that we need to know about your child to insure a safe and comfortable camp experience? NO YES If yes please specify:______

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Parent/Guardian Signature Date