Mailing Address

**PLEASE COMPLETE AND GIVE TO INSTRUCTOR ON 1 DAY OF PROGRAM
Participant Name (Last, First)*
Date of Birth*

MonthDayYear
Date
Mailing Address
Hemlock Farms Street Address*
Parent or LEGAL Guardian*
Best Phone Number to be reached*
Best Phone Accepts Texts?

Accept Texts?
Temporary Care Giver*
Relationship to Participant*
Care Giver Best Phone Number to be reached*
Caregiver Phone Accepts Texts?

Accept Texts?
Parent or Legal Guardian*
Childs Name*
Temporary Caregiver Name*
1st Emergency Contact*
1st Emergency Contact Phone Number to be reached*
1st Emergency Number Accepts Texts?

Accepts texts
2nd Emergency Contact
2nd Emergency Contact Phone number to be reached
2nd Contact Phone Number Accepts Texts?

Accepts Texts
If Participant is a MINOR, please list all individuals who are authorized to pick up the child
Authorized Individual 1*
Authorized Individual 2
Authorized Individual 3
Authorized Individual 4
Health Information
Please provide information on any health history, health issues and all medical information pertinent to participation in the program enrolled.
List all & describe Health Histort*
Additional Health History
Does the participant have any allergies? List all & describe all Allergies*
Additional Allergies
List all medication the participant takes and the reason for medication. All medications should be documented in the event the participant
Medications*
Additional Medications
PLEASE NOTE: If, at any time during a scheduled program, the participant appears to have a contagious or communicable illness, they may not attend the program until cleared by a medical professional. If your failure to disclose the participant’s special needs or health issues jeopardizes the safety of the participant, other program participants or HFCA Staff, the HFCA will not be held liable.
In the event of any EMERGENCY, I authorize Hemlock Farms Community Association staff to secure emergency medical treatment by certified responders, emergency medical personnel and/or in a local, licensed hospital, for any treatment deemed necessary for the participant’s immediate care. If parent / legal guardian or temporary caregiver cannot be reached, standard EMS protocols will be followed, which will include transportation to a local hospital for further evaluation and medical treatment. I agree that I will be responsible for payment of any and all medical services rendered, the HFCA will not be responsible for any fees associated with any medical care or services rendered.
PARENT OR LEGAL GUARDIAN Signature*

Clear
Date

MonthDayYear
Date
Should be Empty:

**PLEASE COMPLETE AND GIVE TO INSTRUCTOR ON 1 DAY OF PROGRAM

Health Information