Kids…Together in the Arts!!!
Emergency form
Please complete the following forms. Fill in the missing information, and sign where indicated. Please return forms by June 15, 2018, with payment.
Name of child: ______DOB: ______
Allergies:______
Parent or guardian #1 name: ______
Address: ______
Home #: ______Cell #: ______
Work #: ______ext.: ______
E-mail: ______
Best way to contact during camp time: ______
Parent or guardian #2 name: ______
Address (if different): ______
Home #: ______Cell #: ______
Work #: ______ext.: ______
E-mail: ______
Best way to contact during camp time: ______
In the event of an emergency and parents cannot be reached, please list two emergency contacts.
Emergency Contact #1 Name: ______Relation to child: ______
Address and phone #: ______
Emergency Contact #2 Name: ______Relation to child: ______
Address and phone #: ______
I hereby give Kids…Together in the Arts!!!Permission to administer basic first aid and/or CPR to my child ______and/or take my child to a hospital for medical treatment when I cannot be reached or when delay would be dangerous to my child’s health.
______
DateParent or Guardian Signature
Physician’s Name______Phone #______
Physician’s Address______
Insurance Information Company Name: ______Policy # ______
HEALTH FORM
The following health form (or a physician’s printout) is required for admission to camp.
Child’s Name:
______Date of Last Examination:______
Height:______ft._____ in.
Weight:______
Record of Immunizations: YearGlasses:______
DPT ______Hearing: (R)______
Td ______(L) ______
Oral Polio ______
Measles ______IS YOUR CHILD ALLERGIC TO:
Mumps ______Insect Bites/Animals:______
Rubella ______Medications:______
Hib ______Food/ Nuts: ______
Hep B ______Other:______
Tuberculin Test ______
Other ______
Physician’s comments and recommendations:
______
______
Illnesses & Injuries (chronic or recurring, check those that apply):
___Ear Infection ___Heart Defect ___Bleeding/Clotting Disorders ___Seizures ___Hypertension ___Muscular skeletal Disorders ___Diabetes ___Asthma
___Heart Disease ___Kidney Disease ___Meningitis ___Hepatitis ___Cancer
___High Blood Pressure ___Hay Fever ___Epipen Carrier ___Tuberculosis
___Eye Condition ___Nose Condition ___Strep/Tonsiltis ___Hernia ___Eczema
___Anxiety ___Depression ___ Headache___ Other ______
Since last health exam, has your child had:
Any prescribed or over the counter drugs? ______
Restrictions concerning physical activity? ______
Any illnesses lasting more than 5 days? ______.
Treatment in the hospital or emergency room? ______
A surgical procedure or fracture? ______
Does your child use prescribed or over the counter drugs? ______
Is your child currently under the care of any physician or psychologist?______
Please explain any yes answers to the above questions. ______
Physician’s Authorization: This person is in satisfactory condition and may engage in all usual activities except as noted.
Licensed Physicians Printed Name:______Phone:______
Licensed Physician’s Signature:______Date:______
Street Address: ______
City:______State:______Zip:______
************************************************************************
RELEASE FORM
I give permission for my child, ______, to be released from the program and/or to be received at the end of the day by the following people:
Name: ______Relation to child: ______
Address: ______Phone #: ______
Name: ______Relation to child: ______
Address: ______Phone #: ______
Name: ______Relation to child: ______
Address: ______Phone #: ______
I authorize Kids…Together in the Arts!!! to use a picture or videotape of my child for purposes of brochures, newsletter, the Kids…Together in the Arts!!! website and other media related to the promotion of the program. ___Yes ___No
************************************************************************
WAIVER
Please accept the above named child(ren) as a VOLUNTARY PARTICIPANT in said Kids…Together in the Arts!!! 2015 SummerArts Program. I freely accept and voluntarily assume all risks of injury and understand it is impossible to predict every situation that might arise through my child(ren)’s participation. I elect to have my child(ren) participate in spite of these risks. I also agree to discuss and fully inform my child(ren) of these potential risks. I do hereby release, indemnify and hold harmless Kids…Together in the Arts, its agents, employees, organizers, participants and Spontaneous Celebrations from any liability/accident claims in case of injury to my child(ren). I do, likewise, release them from any and all present and future claims resulting from ordinary negligence on their part. Also, I assume full responsibility and certify my child(ren) is in good physical and emotional health and is capable to participate in this activity. I am aware this program provides NO HEALTH/ACCIDENT INSURANCE and that this is my responsibility. I have read and fully understand the contents of this waiver and I am signing it on behalf of my child(ren). I realize it is binding, now and forever, on myself, my child(ren), my heirs and assigns.
Parent/Guardian: ______Date: ______