Summer SMART Registration Form

ALLERGY INFORMATION

PLEASE COMPLETE THIS FORM EVEN IF YOUR CHILD HAS NO KNOWN ALLERGIES
Food Allergies *

Yes No
List your child's food allergies, the severity and treatment needed to administer.
Medication Allergies *

Yes No
List any medication your child is allergic too.
Does your child use any form of medication in an emergency exposure? *

Yes No
List any medication form of medication in and emergency exposure. (Ventolyn Benadryl, Bee sting kit etc...)
If your child does use a medication in the event of an emergency exposure, please bring the LABELED medication with FULL WRITTEN INSTRUCTIONS FOR USE AND UNDER WHAT SPECIFIC CONDITIONS IT SHOULD BE ADMINISTRATED.

Medical Permission Form:
By signing this registration form, I give permission for my child named below to receive emergency treatment and to be hospitalized at my expense, if necessary. I understand
Child's Name
Parent/Guardian Initials
Medical Insurance
Policy Number
Child's Physician
Physician's Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Physician's Phone Number

Area Code Phone Number

Medical Records and Custody
Do you have any custody agreement, court orders, and restraining orders pertaining to the child named above.

Yes No
Special limitations or concerns.
I certify the documentation of physical examination and immunization in accordance with public school health requirements and lead paint poisoning screening in accordance with public health requirements are on file at my child's school
Parent Guardian
Parent Guardian

Medication Consent form
Child Name

First Name Last Name
Name of Medication
Is the medication

Prescription Non Prescription
Dosage
Date Medication to be given
Times Medication to be given
Reason for medication
Possible side effects
Directions for storage
I parent/guardian named below, give permission to BBTMusic authorized staff members to administer medication to my child as indicated above.
Parent/Guardian Name

Parent/Guardian 1 Work Information