Emergency Medical Consent Form

The Emergency Medical Consent Form is valid for 1 year and may be updated anytime by the parent or legal guardian.

I, Your Name declare that I am the legal guardian of, Child's Name , born on Date .

Emergency Contact Phone Number*

Please enter a valid phone number.

Please list any special or adaptive needs for your child:

Health Conditions and Allergies - Please be specific in listing food and environmental allergies, conditions, and reactions:

My child takes the following medications:

Do you give permission for your child to receive medical treatment in the event of an emergency?**

YesNo

Signature

Today's Date

Date

*Access Arts staff and volunteers will not administer any medications. In the event of an emergency, this information will be given to medical personnel

**Access Arts does not provide medical insurance for camp participants. Parents or caregivers are responsible for providing such insurance and for payment of any medical expenses for a child not covered by insurance.