AIM Member S Identification Record: 20 20

Art In Motion: Identification Form

updated June 2016

AIM Member’s Identification Record: 20 −20 .

Member’s Full Legal Name:
Preferred Name: / Gender: / DOB:
Address: / Zip:
Mother’s Name: / Phone:
Address: / Zip:
email:
Place of Employment: / Phone:
Father’s Name: / Phone:
Address: / Zip:
email:
Place of Employment: / Phone:
Who has legal custody: / Relationship:

Persons permitted to remove child:

Name: / Phone:
Name: / Phone:

IN CASE of EMERGENCY, persons to be notified when parent or guardian cannot be reached:

Name: / Phone:
Name: / Phone:
Member’s Physician: / Phone:
Allergies:
Medical conditions to be aware of

I give permission to consult the child’s physician/health resource listed above in case of an emergency if parent cannot be reached.

X:
Signature of parent or legal guardian / Date

2330 Curlew Rd, Palm Harbor FL 34683

727-786-8111

(727)-786-8111