Emergency Medical Form K12 Gallery&Tejassummer 2018

EMERGENCY MEDICAL FORM – K12 GALLERY&TEJASSUMMER 2018

An Emergency Medical Form must be submitted for each child attending youth art camps. This form should be completedand returned to K12 GalleryTEJAS prior to the start of the camp OR can be turned in when the participant checksin for his/her first day of camp.

PARTICIPANT INFORMATION

Student’sFull Name______

Date of Birth ______Grade entering in Fall 2017______

Home address______

City______State______Zip code______

My child will be attending classes or camps the following week(s) (Please circle):

Week 1: June 4-8 Week 2: June 11-15 Week 3: June 18-22 Week 4: June 25-29 Week 5: July 9-13 Week 6: July 16-20 Week 7: July 23-27 Week 8: Jul 30-Aug 3 Week 5: Aug 6-10

PARENT/GAURDIAN INFORMATION

Parent/Guardian #1 Name______

Parent/Guardian #2 Name______

Contact Info for Guardian #1 Contact Info for Guardian #2

Place of work______Place of work______

Cell Phone ______Cell Phone ______

Work Phone ______Work Phone ______

Home Phone ______

Email: ______

Additional Emergency Contact ______

Relationship to student ______

Home Phone______Cell Phone______

PARENT APPROVED MODES OF TRANSPORTATION

Please indicate how your child will arrive/depart each day

______Dropped Off & Picked Up by Parents/Guardians ______Driving Themselves

______Dropped Off & Picked Up by Other ______Walking/Biking ______Taking the Bus

Names of people approved to pick up/drop off student (Maximum Two):

______

MEDICAL INFORMATION

Does the student have any medical conditions that staff should be award of? ______yes ______no

If yes, please describe: ______

______

Will the student be taking medications while at K12 Gallery? ______yes ______no

Will the student be administering their own medication? ______yes ______no

Will the student need staff to administer a medication for them? ______yes ______no

Please list all medications:

Medication______Dosage______Take at what times______

Please list whatever medications the student will need to carry due to any life threatening conditions (i.e. bee sting kits, inhalers):

Medication______Dosage______When to use______

Does the student have any allergies we should be aware of? ______yes ______no

Please list all allergies (and allergy related info you would like staff to be aware of): ______

______

Family Physician’s Name: ______Phone ______

In the event of an accident, injury, or sudden illness, I give consent for my child to receive emergency medical treatment, including emergency medical transportation, by a healthcare professional.

Signature of parent/guardian______Date______