Kids Art Program Emergency Contact & Medical Information Form
Please fill out the form below for our records one week prior to your child attending the Saratoga Arts Summer Art Program. If you have any additional questions or concerns, please email our staff at education@saratoga-arts.org or 518-584-4132.
Child's First and Last Name:
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Age of child
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6
7
8
9
10
11
12
13
Grade of child
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Grades 1-3
Grades 4-6
Grades 6-9
Pronoun of child
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He/Him
She/Her
They/Them
Address:
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Emergency Contact #1:
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Relation to Child:
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Phone
*
Email
*
Emergency Contact #2:
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Relation to Child:
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Phone
*
Additional Authorized Adults to Pickup & Phone:
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School District
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School Name
*
Past Camp Registrant
*
No, this is the first time my child is attending Saratoga Arts Camp
Yes
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Medical Information
Physician's Name:
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Physician's Phone:
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Immunization Records: Please include documentation by downloading in this form (next question), email or mail your child’s most up-to-date immunization record and physical examination form from your pediatrician to education@saratoga-arts.org, 320 Broadway, Saratoga Springs, NY 12866. **Children returning to camp across multiple weeks will only need to submit once within the 2025 calendar year. Please note: We do not have a fax number.
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I will email a digital copy
Provider will email a digital copy
Provider will mail a physical copy
I will mail a phsycial copy
I will attach documents below
Attach required medical information here
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Does your child have any allergies:
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Yes
No
If yes, please specify triggers, timing, required treatments, etc.
Does your child require any medications?
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Yes
No
If yes, please specify drug and condition:
Can your child self-carry prescribed medication during summer program?
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Yes
No
Does your child have any dietary restrictions?
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Yes
No
If yes, please specify
Does your child have any hearing, visual, dental conditions?
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Yes
No
If yes, please specify what conditions
Does your child have any medical conditions?
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Yes
No
If yes, please specify
Does your child have any developmental conditions?
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Yes
No
If yes, please specify
Please provide any additional information about your child that Saratoga Arts' staff should know about your child
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Marketing & Photo Release
Does Saratoga Arts have permission to use photos of your child in our marketing materials?*This includes social media, website, print mail, print advertising**
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Yes
No
Where did you learn about this camp?
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Mailer
Website
Facebook
Instragram
Reels
At the Gallery
From a SA Staff Member
Email
Capital District Moms
Mini City Online
Saratoga.Com
Kids Out & About
Other
If other, where?
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Memo of Understanding and Medical/Liability Release Form
1. It is the responsibility of the parent to provide lunches and snacks
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I agree
2. It is understood that students are not allowed to share snacks or eating utensils
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I agree
3. It is understood that teachers or staff members will not give your child food
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I agree
4. It is understood that the parent will provide emergency medications needed at camp and sign this form
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I agree
5. Furthermore, I (we) and on behalf of my (our) child/participant, hereby assume all risk of personal injury, sickness, death, damage, and expense as a result of participation in recreation and activities involved therein.
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I agree
6. The undersigned further hereby agrees to hold harmless and indemnity said Saratoga Arts, their directors and agents, for any liabilities sustained by said Saratoga Arts Summer programs, their directors and agents as the result of the negligent, willful or intentional act(s) of said participant, including expenses incurred attendant thereto.
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I agree
7. I (we) am (are) the parent (s) of legal guardian (s) of this child-participant, and hereby grant my (our) permission for him or her to participate in activities of said camp, and hereby give my (our) permission to take said participant to a doctor or hospital and hereby authorize medical treatment, including but not in limitation to emergency surgery or medical treatments, and assume the responsibility of all medical bills, if any. Further, should it be necessary for the child/participant to return home due to medical reasons, disciplinary or otherwise, the parent or guardian will pick up the child/participant.
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I agree
8. In the event of an emergency requiring medical treatment, I give permission to the Saratoga Arts staff to obtain the services of a licensed physician. Please notify me immediately of any such emergency.
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I agree
Signature
Date:
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Day
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