EMERGENCY FORM

We respect your privacy and will not share your information with any 3rd party

Student's Name

Student's Birthdate

MonthDayYear

Student's Age

PARENT'S CONTACT INFORMATION

Parent #1's Name

Parent #1's Home Phone

Parent #1's Cell Phone

Parent #1's Work Phone

Parent #1's Mailing Address

Parent #1's Email Address

_________________________________________________________

Parent #2's Name

Parent #2's Home Phone

Parent #2's Cell Phone

Parent #2's Work Phone

Parent #2's Mailing Address

Parent #2's Email Address

_________________________________________________________

EMERGENCY CONTACT

Emergency Contact

Phone

Relationship

_________________________________________________________

PHYSICIAN'S INFORMATION

Physician's Name

Phone

Health Insurance Provider

_________________________________________________________

PICK-UP AUTHORIZATION

The following people have my permission to pick up my child from Davis Studio:

Name

Phone

Relationship

Name

Phone

Relationship

_______________________________________________________

How did you hear about Davis Studio (i.e. friend’s recommendation, camp fair, newspaper ad, on-line ad, etc.) ?

MEDICAL PROFILE

Please list any medical issues or allergies that might affect your child's participation in the program

Medical Issues

Allergies

Behavioral Issues

I hereby represent that the minor is in good health, and that I have identified all medical conditions associated with the minor, and that I have adequately informed Davis Studio personnel of any special instructions regarding the minor. I certify that I have adequate insurance to cover any injury or damage the minor may suffer while participating, or else I agree to bear the costs of such injury or damage myself. I give the staff at Davis Studio permission to authorize emergency medical attention should it be required.

Your name / date:

Kids Emergency Form

PARENT'S CONTACT INFORMATION

EMERGENCY CONTACT

PHYSICIAN'S INFORMATION

PICK-UP AUTHORIZATION

MEDICAL PROFILE