Kids Emergency Form

Kids Emergency Form
We respect your privacy and will not share your information with any 3rd party
Student's Name
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: