Permission | Health Form

Art Castle Camps-Permission|Health

This form allows your child to take part in walking field trips, gives us necessary medical information and lets us know who is authorized to pick up your child.
This form must be completed and on file for your child to participate.
Camper's Name*

First NameLast Name
Age*
Address*

Street Address

Street Address Line 2

City, State ZipState / Province

Postal / Zip Code
Name of Camp(s):
YesNo
Yes, please charge my card on fileNo, I will call in payment or provide a checkNot Applicable - My child is not at The Arts Castle for lunch time.
Parent/Guardian Information
Parent Name*

First NameLast Name
Cell Number*
Format: (000) 000-0000.
Work Number
Format: (000) 000-0000.
E-mail*
example@example.com
By PhoneBy TextBy E-mail
Emergency/Medical Information
If you are not reachable, what is name of another adult to whom the student may be released/who may be contacted in case of emergency:
Emergency Contact's Name*

First NameLast Name
Relationship*
Cell Phone Number*
Format: (000) 000-0000.
Alt. Phone Number
Format: (000) 000-0000.
Others authorized to pick up student: Please list name and relationship.
Does your child have any allergies, chronic illness, or medical conditions? If yes, please describe.
Are there any medications your child needs to take while at camp?

If students typically keep these medications with them at school, then students may keep these medications with them at camp. (ex. EPI-Pens, Insulin Kits, Inhalers, etc).

For other medications, please put the medication in its original packaging in a Ziploc bag with the student’s name, medication name, dosage, and time of administration clearly marked on the bag, and turn it in to the Arts Castle instructor on the first day of camp. Students will administer their own medication.
Medications:
Please list any other information you think we should know regarding your child:
Medical Release and Authorization

In the event reasonable attempts to contact me and the designated emergency contact have been unsuccessful, as Parent and/or Guardian of the named child, I hereby give my consent for the administration of any treatment deemed necessary and/or the transfer of my child to any hospital reasonably accessible.
Medical Release and Authorization*
Walking Field Trip Consent

I give permission for my child to accompany The Arts Castle summer camp program on walking field trips in the immediate area of The Arts Castle during the time he/she is at camp.
Walking Field Trip Consent:*
Participant Waiver

By registering you grant permission for the The Arts Castle to use photographs and/or videos of you or your child in publications, marketing materials, website, social media and in other communications related to the mission of The Arts Castle.

Also, I release and discharge the Delaware County Cultural Arts Center (The Arts Castle), their agents and employees for any damages, actions, demands and injuries arising out of any participation in this activity.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT and WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Signature*

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Date*

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Art Castle Camps-Permission|Health