Years of participation blanks New applicant? blank Child's information First Name Last Name Address Street Address Address Line 2 City State Zip
Name of School blanks Teacher's Name blank Grade Number*
Parent/ Guardian InformationName blanks Relationship blank Address (if different from above) Street Address Address Line 2 City State Zip Area Code Home phone Phone Number Cell phone Area Code Phone Number Work phone Area Code Phone Number Emergency Contact Person First Name Last Name Phone Area Code Phone Number
1. The African American Cultural Center may use me and/ or my child's likeness, voice and name for the purposes of advertising, publicity and sales promotion, but not as a direct endorsement of any particular product or service.
2. I acknowledge that I have not been promised, and do not expect to receive any fee, payment, reimbursement, or other remuneration i nconnection with the programming, but that I have agreed to allow me and/ or my child(ren) to appear for purely personal considerations.
Agreed to and accepted this day of Date Child's name First Name Last Name Parent's signature Signature
I give my son/daughter permission to attend the field trips associated with participation in the Jumpin' Jambalaya Summer Program.
All field trips are scheduled to leave on time. If your child arrives late and the provided transportation has departed, you must make other arrangements for your child's care. There will not be anyone at the Center to provide you services for your child/children.
THE AGENCY'S STAFF IS NOT PERMITTED TO ADMINISTER MEDICATION OF ANY KIND FOR EMERGENCY PURPOSES. PLEASE LIST BELOW ANY PHYSICAL, PSYCHOLOGICAL, MEDICAL OR OTHER CONDITIONS REQUIRING SPECIAL ATTENTION OR CARE. Therefore, in the vent of illness or injury, we will contact you for your advice pertaining to this child. AMR WNY will transport the child to Oshei Children's hospital 818 Ellicott Street Buffalo, NY 14203. An administrative staff member will remain with the child until the parent/ guardian arrives.
Name of child's Physician blanks Physician's phone number blank
A copy of your child's immunization records is a requirement by the Erie County Health Department and the New York State Department of Health. Records must be dropped off at the African American Cultural Center prior to your child attendance. The following immunizations are required to enter the summer camp: Diphtheria, Hemo philus Influenza B, Hepatitis B, Measles, Mumps, Poliomyelitis, Rubella (German Measles), Tetanus and Varicella (Chicken Pox).
If yes, are there any restrictions based on the examination i.e, dancing, running, jumping, etc.? blanks Is the child allergic to any medications, insect stings or foods? blank
Does the child experience any of the following health problems? Eye, ear, nose, throat, bleeding, clotting disorders, lung problems, hay fever, asthma, seizures, convulsions or heart problems? If yes, please explain blanks Are there any food restrictions? If yes, please explain blank