Summer Cheer Camp Medical and Dietary Form
Participant Information
Participant's Name
*
First Name
Last Name
Age
*
Pronoun
*
Please Select
He/Him/His
She/Her/Hers
They/Them/Theirs
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Information
Name 1
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
Relationship
*
Name 2
First Name
Last Name
Phone Number
Format: (000) 000-0000.
Relationship
Emergency Contact Information
Emergency Contact Person
*
Medical and Dietary Information
Will the participant require medication while at camp?
*
Please Select
Yes
No
If you answered "yes", you agree to administer medication to the participant as necessary. KDA will not be responsible for adminstering medication to the participant.
Does the child have any allergies, chronic illness, or medical conditions? If yes, please describe.
*
Please Select
Yes
No
Please list all allergies, chronic illness or medical conditions here.
*
If you answered "yes', to the question above, will these conditions prevent the participant from fully participating in the camp?
*
Please Select
Yes
No
If you answered "yes", please explain how the participant will be prevented from fully participating in the camp.
*
Does the participant have any food allergies?
*
Please Select
Yes
No
If you answered "yes", please list all food allergies.
*
Does the participant have dietary needs or restrictions?
*
Please Select
Yes
No
If you answered "yes", please list all dietary needs and/or restrictions here.
*
Acknowledgment and Release
*
I authorize the Klohverleaf Dance Academy to render basic first aid as needed.
I release the Klohverleaf Dance Academy of any liability, damage, or costs incurred for any accidents or injuries during the Summer Cheer Camp.
Parent/Guardian Signature
Submit
Should be Empty: