Children's Programs Health and Dismissal Form Please enable JavaScript in your browser to complete this form.Child's Name *FirstLastDate of Birth *YYYY-MM-DDDoes your child have a support worker at school? *YesNoIf yes, do they require one-to-one support (copy)YesNoDoes your child require medication? *YesNoIf yes, please list medications:Is your child anaphylactic? *YesNoIf yes, do they carry an epipen?YesNoIf yes, are they trained to administer the epipen?YesNoEmergency Contacts:Parent/Guardian (1) Name *FirstLastParent/Guardian (1) Daytime Phone # *Parent/Guardian (1) Alternative Phone # *My child my sign themself out after camp each day *YesNoAdditional Parents/GuardiansAdditional parents and guardians who are authorized to pick up my child from camp and be contacted in an emergency.Parent/Guardian (2) Name *FirstLastParent/Guardian (2) Phone # *Parent/Guardian (2) Relationship to Child: *Parent/Guardian (3) NameFirstLastParent/Guardian (3) Phone #Parent/Guardian (3) Relationship to Child:Photo ReleaseDo you authorize a photo release? *YesNoSubmit To return to the childrens programs page, click here.
