Children's Programs Health and Dismissal Form

Child's Name

First

Last

Date of Birth

YYYY-MM-DD

Does your child have a support worker at school?

If yes, do they require one-to-one support

If yes, please describe support required

Does your child require medication?

If yes, please list medications:

Is your child anaphylactic?

If yes, do they carry an epipen?

If yes, are they trained to administer the epipen?

My child may sign themself out after camp each day

Parent/Guardian (1) Name

First

Last

Parent/Guardian (1) Daytime Phone #

Parent/Guardian (1) Alternative Phone #

Additional parents and guardians who are authorized to pick up my child from camp and be contacted in an emergency.

Parent/Guardian (2) Name

First

Last

Parent/Guardian (2) Phone #

Parent/Guardian (2) Relationship to Child:

Parent/Guardian (3) Name

First

Last

Parent/Guardian (3) Phone #

Parent/Guardian (3) Relationship to Child:

Do you authorize a photo release?

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