Smartnet Summer Program Form

Emergency Contact
Besides the parents, list anyone else you approve to pick up your child from Pyramid CDC - Computer Technology and Entrepreneurship Readiness Program and/or be contacted in case of emergency, if we cannot reach a parent/ guardian.
Emergency Contact(s) Name *

First NameLast Name
Relationship to Child*
Phone Number*
Please enter a valid phone number.
Additional Authorized Pick Up

First NameLast Name
Relationship to Child
Phone Number
Please enter a valid phone number.

Medical Information
Primary Physician Or Medical Clinic
Phone Number
Please enter a valid phone number.
Dentist or Dental Clinic
Phone Number
Please enter a valid phone number.
Does your child have any allergies, illnesses, or other medical diagnoses that may affect them during the Program?*

YesNo
If yes, please list them:*
Does your child have any dietary restrictions?*

YesNo
If yes, please describe*
Does your child take any medications?*

YesNo
If yes, please list the medication, dosage,and frequency*
Pyramid CDC Counselors shall not administer medication to participants of the Pyramid CDC - Computer Technology and Entrepreneurship Readiness Program. All medication taken by participants shall be self-administered. No participant shall be registered into the Program unless that individual is capable of taking his/her own medications, or a parent/guardian is available to administer the medication. Pyramid CDC Counselors may 1.) Remind a participant to take medication, and 2.) Assist participants by storing and handing the medication to the participant.*

I understand
Is your child covered by any Hospital/Medical Care Policy?*

YesNo
Doctor's Name
Phone Number
Please enter a valid phone number.