Emergency Contact Form Youth Programs printable pdf download

Emergency Contact Form

Youth Programs

Student Name ___________________________

Date of Birth _________________ Age_______

Primary Emergency Contact

Secondary Emergency Contact

Name __________________________________

Email ________________________________

Cell phone______________________________

Cell phone_______________________________

Work phone_____________________________

Relationship_____________________________

Please list all known allergies (i.e. foods, medications, bees, etc.)

Please list all known medical conditions (i.e. asthma, attention disorder, learning disabilities, etc.)

Please list all medications your child takes, including doses, frequency, and purpose.

Please list any activity restrictions your child may have.

Is there other information you would like to share about your child’s health or well-being?

(Please feel free to use the reverse of this form.)

Permissions

☐

I give consent for my child to be treated by a physician in the event of a medical emergency whereby

the emergency contacts cannot be reached. I also give consent to release medical information to

healthcare providers in the event of necessary care.

I give consent for my child to leave the campus of the Maine College of Art, under supervision, for

inclusion in field trips, lunch in our Green Space, and/or off-campus art instruction.

☐

I understand that photos of students and their work taken during the program may be used in future

publications to promote the program. Children’s names will never be used.

My child is registered for a Teen class and may leave campus unattended for lunch.

My child may leave campus on his/her own at the end of class (to walk home, to my office, etc.)

Pick Up Authorization: My child may be picked up by the following adults. Please print clearly.

We reserve the right to ask for ID at pick up.

_____________________________________________________________________________________

Parent/Legal Guardian Signature _________________________________

Date ________________

Emergency Contact Form Youth Programs