ARTWORKS HEALTH FORM
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Name of Participant:
What session(s) would you like to attend?
(check all that apply)
Session 1: June 5 - June 16
Session 2: June 19 - June 30
Session 3: July 3 - July 14
Any combination of sessions may be chosen. Class content is altered in every session so that each session is unique.
Parent (Guardian) Name:
Mother's Daytime Phone:
Mother's cell Phone:
Father's Daytime Phone:
Father's cell Phone:
Emergency Contact Name:
Emergency Contact Phone:
Please list any allergies that might affect participation at Artworks. Include food, drug, or environmental allergies.
Is your child being treated for emotional
problems or hyperactivity?
If yes, briefly describe, include any medication being taken:
My child has the following medication that must be taken during camp hours:
Additional information staff neds to know: (e.g. emotional problems, physical limitations, etc.
Date of last tetanus shot:
, IS A FULLY ENROLLED PARTICIPANT IN THE ARTWORKS PROGRAM. I AUTHORIZE YOU TO ADMINISTER ANY EMERGENCY MEDICAL TREATMENT NECESSARY TO INSURE THE WELL-BEING OF MY CHILD.I UNDERSTAND THAT EVERY EFFORT WILL BE MADE TO REACH ME IN CASE OF EMERGENCY AND THAT MY EMERGENCY REFERENCE ABOVE WILL BE NOTIFIED IF I CANNOT BE REACHED.I/WE ARE COVERED FOR EMERGENCY MEDICAL SERVICES BY
(name of insurance company) AND THAT MY/OUR POLICY NUMBER
I give permission for photos containing my child (no names will be posted) to be posted on:
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