Summer Art Camps 2018: Medical Information and Release Form

Parent/Guardian #2
Please complete this section if applicable. If there is not a second parent or guardian contact, you may click "NEXT" at the bottom of the page and skip this section.
Name of Parent or Legal Guardian

First NameLast Name
Relation

MotherFatherLegal Guardian
Secondary Contact: Home Address

Same as ChildDifferent Address
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number

Area CodePhone Number
Secondary Phone Number

Area CodePhone Number
Other Phone Number

Area CodePhone Number
E-mail

Emergency Contact
Is there anyone else, other than the parents/guardians, whom you would like to list as an emergency contact?*

YesNo
Full Name*

First NameLast Name
Relationship to child*
Primary Phone Number*

Area CodePhone Number
Secondary Phone Number

Area CodePhone Number
Is the Emergency Contact also authorized to pick-up your child?*

YesNo

Names & relationship of people other than parents/guardians and emergency contact to whom the child may be released
Is there anyone else to whom your child may be released?*

YesNo
Full Name

First NameLast Name
Phone Number

Area CodePhone Number
Full Name

First NameLast Name
Phone Number

Area CodePhone Number
Full Name

First NameLast Name
Phone Number

Area CodePhone Number
Full Name

First NameLast Name
Phone Number

Area CodePhone Number
Full Name

First NameLast Name
Phone Number

Area CodePhone Number
Full Name

First NameLast Name
Phone Number

Area CodePhone Number

Health Information
Name of Physician or Clinic*
If you do not have a physician or Health Clinic, please write "NONE"
Physician's or Health Clinic's Phone Number*
If you do not have a physician or Health Clinic, please write "NONE"
Health Insurance Carrier*
If your child does not have health insurance, write "NONE"
Health Insurance Policy Number*
If your child does not have health insurance, write "NONE"
Hospital Preferred for Emergency Treatment*
If you have no preference, please write "NO PREFERENCE"
Is your child up to date on their childhood immunizations?*
If you are not sure, please write "UNKNOWN"
Date of Last Tetanus Shot*
If you are not sure of the date, please write "UNKNOWN"

Health Information or Special Concerns
Does your child have any allergies?*

YesNo
If your child has allergies, please list them here. Include the level of severity and any additional information we should be aware of*
Does your child have asthma?*

YesNo
If your child has asthma, please list the level of severity and any additional information we should be aware of*
Does your child have any other medical conditions, learning differences, or special needs? If so, please describe. (If relevant, include any strategies you recommend to best address your child's needs.) If there are none of the above, please type "NONE".*
If your child will require any special accommodations or you would like to discuss strategies for best meeting the needs of your child, please reach out directly to the Camp Director at rderocher@annarborartcenter.org or 734-926-4129.

Medical Administration Authorization
List any medications your child is currently taking*
If your child is not currently taking any medications, please type "NONE"
Will your child be bringing any prescription or non-prescription medication to camp?*

YesNo
All medications must be submitted in the original container/packaging and sealed inside a ziploc bag with the child's first and last name on it.

Please Note: Any parents that prefer their child to self-carry/self-administer emergency medications such as EpiPens, Inhalers, etc., must also complete a "Self-Carry/Self-Administration of Emergency Medication Authorization Form". Please contact the Camp Director to request a form. It requires the signature of your child's physician.
Medication*
Condition for which medication is required*
Dosage*
Time/Frequency of Medication Administration*
Any relevant side effects*
Any additional notes*
Is there a second medication that your child will be bringing to camp?*

YesNo
Medication*
Condition for which medication is required*
Dosage*
Time/Frequency of Medication Administration*
Any relevant side effects*
Any additional notes*
Is there a third medication that your child will be bringing to camp?

YesNo
Medication*
Condition for which medication is required*
Dosage*
Time/Frequency of Medication Administration*
Any relevant side effects*
Any additional notes?*
I request designated camp personnel to administer the medication listed above. I certify that I have the legal authority to consent to medical treatment for the camper named above, including the administration of medication at the facility. I understand that at the end of each camp session, an adult must pick up the medication or it may be discarded.*

I have read and agree to this statement
Signature*

Clear

Liability Release
I understand that the physical activities which my child may participate in Art Camp include, but may not be limited to,stretching, walking, running, going up and down stairs, playing, travel (by walking), interactions, off-site activities, the use of equipment and supplies, and any other activities as directed by the Art Center (collectively, the “Activities”).I release, waive, and discharge, on my behalf, on behalf of any family members, on behalf of my child, and on behalf of all of any of their heirs (collectively the “Releasors”) the Ann Arbor Art Center and the Doughty Montessori School Play Yard, its instructors, staff, officers, directors, contractors, volunteers, and agents, or anyone acting on their behalfs (collectively, the “Art Center”) from any and all claims, liability, losses, illnesses, injuries, acts, omissions, and/or damages in any way related to the Activities, even if that may arise out of negligence. The Releasors recognize that the Activities may result in the risk of injury, illness, death, danger, or accidents, and the Releasors knowingly assume those risks.

Releasors acknowledge the contagious and potentially deadly nature of COVID-19. Releasors further acknowledge that the Art Center does not guarantee or represent that they will not become infected with or spread COVID-19. Releasors acknowledge that parents/guardians and participants must comply with all set procedures to reduce the spread while attending camp. In return for being permitted to be in the Ann Arbor Art Center and the Doughty Montessori School Play Yard and participate in the Activities, in the event that my child or any other person contracts COVID-19 or any other disease, Releasors further hereby irrevocably waive and discharge any and all claims, damages, or actions that they have, may have, or could have against the Art Center and the Doughty Montessori School (who provides the Art Center Summer Art Camps access to and use of their play yard).

This acknowledges that my child is in good health and that any allergies, medical conditions, special needs or concerns, activity restrictions and medications taken by the child are noted on this form. I authorize the Ann Arbor Art Center to provide routine, nonsurgical medical care and to secure emergency medical and/or emergency surgical treatment for the minor child while in its care.

I hereby give permission for my child to walk supervised to the Doughty Montessori School play yard and participate in outdoor supervised activities anywhere within the area of 1St. to 5th Ave. and Jefferson St. to Washington St. Releasors further release the Art Center from any liability for loss or damage to personal property or for the risk of injury or illness on account of my child’s presence at the properties or in transit to them.
Each of the releases above are cumulative. Releasors agree to the above in consideration for the child’s participation in the Ann Arbor Art Center programs.*

I have read and agree to this statement.
Signature*

Clear
Photography & Recording Permission
Releasors hereby irrevocably release consent and allow theAnn Arbor Art Center and its agents to use their child’sphotograph/artwork/likeness/voice/image, as it pertains to participation withthe Art Camps, in any manner for promotional efforts without expectation of anyreimbursement in connection with its use.*

YesNo
If Yes, Please sign below

Clear
Should be Empty:

Summer Art Camps 2023: Medical Information and Release Form

Child's Information

Parent/Guardian #1- Primary Contact

Parent/Guardian #2

Emergency Contact

Names & relationship of people other than parents/guardians and emergency contact to whom the child may be released

Health Information

Health Information or Special Concerns

Medical Administration Authorization

Liability Release

Photography & Recording Permission