Holiday Workshop Form
Child's Full Name
*
First Name
Last Name
Child's Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child lives with:
Mother
Father
Guardian
Parent or Guardian's Full Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
Work Number
*
Format: (000) 000-0000.
E-mail
example@example.com
Parent or Guardian's Full Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
Work Number
*
Format: (000) 000-0000.
E-mail
example@example.com
Please select the workshops you would like to enroll in.
Monday, November 23rd - Thanksgiving Holiday
Tuesday, November 24th - Thanksgiving Holiday
Emergency Contact Information
The following people are authorized to pick up my child and may be contacted in case of an emergency or illness in the event I cannot be reached.
Signature
Emergency Contact Person 1
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
Alt. Number
*
Format: (000) 000-0000.
Relationship to Child
Emergency Contact Person 2
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
Alt. Number
*
Format: (000) 000-0000.
Relationship to Child
Consent for Medical Care & Treatment
I give permission for the licensed provider or qualified staff to administer first aid/emergency medical treatment to my child/children. When I cannot be contacted, I authorize and consent to medical, surgical, and hospital care, treatment and procedure to be performed for my child by a licensed physician, health care provider, hospital or ambulance when deemed necessary or advisable by the physician or ambulance to safe guard my child’s health.
Signature
Additional Authorized Pick-Ups
The following people have my permission to pick up my child.
Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
Child's Health Information
General State of Health:
Does your child have any known allergies?
Yes
No
If yes, please list your child's allergies.
Are you concerned that your child may have allergies?
Yes
No
If yes, please describe
Does your child have any medical conditions I should be aware of?
Is your child on any long- term medications?
Does your child have any speech, hearing, or visual problems?
Does your child have any restrictions on play?
About Your Child
Are there any food restrictions?
Yes
No
If yes, please list.
Are there any other comments or information you would like to let me know about your child?
The undersigned, being the lawful parent and/or guardian(s) of the above child, hereby consent to the participation by the child in all activities conducted by Play Smarter Kids. I understand that my child's participation in Play Smarter Kids programs is completely voluntary.Play Smarter Kids is in no way responsible for any injuries that may take place while in care and assume all risk of injury to my child associated with participation in Play Smarter Kids programs. Parent or Guardian Signature
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