Sample Student Emergency Contact Form printable pdf download

YOUNG AT ART

EMERGENCY CONTACT FORM

Today’s Date: _________________________________________

Student’s Name_________________________________________________________________ Grade_____________ DOB____________________

Address_________________________________________________________________________________________________________________________

City____________________________________________________________________________State___________________Zip_____________________

Email__________________________________________________________________ Main Phone___________________________________________

Mother/Father___________________________________________________________________ Phone______________________________________

Babysitter ________________________________________________________________________ Phone____________________________________

PLEASE LIST AN ALTERNATIVE CONTACT IF YOU CANNOT BE REACHED IN AN EMERGENCY:

Name______________________________________Relationship___________________________Phone_____________________________________

Allergies_______________________________________________________________________ Asthma: YES / NO EPI-Pen: YES / NO

MEDICAL CONSENT

I waive any liability against YOUNG AT ART STUDIO INC for injury, illness, or loss of property.

I hereby give my permission to the staff of YOUNG AT ART STUDIO INC to take my child ___________________________to

a local hospital emergency room if I cannot be reached and that all necessary treatment can be given at that time.

Signed_____________________________________________________________________________________ Dated _____________________________

PHOTO/VIDEO/SOCIAL MEDIA RELEASE

Each week, Young at Art posts photos of each class on our Facebook page (Young at Art Workshop) and

Instagram (youngatartworkhop), so that parents can see what their child is working on in class. No names or

identifying information is posted. We do not tag the photos. By signing below, you are giving permission for

Young at Art to post photos of your child.

I give my permission to YOUNG AT ART STUDIO INC to take photos and/or videos of my child to be used in public

relations materials and to be posted on social media outlets, such as Facebook, Twitter, Instagram, and on the

Young at Art website.

Signed________________________________________________________________________________________ Dated __________________________

Sample Student Emergency Contact Form