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Creativeartsatpark.org

Emergency Medical Information
GENERAL INFORMATION
Full Name of Child ____________________________________ Nickname ____________________ Date of Birth_________ M / FParent(s)/guardian(s) _________________________________ Daytime Phone _________________ Cell Phone ________________Parent(s)/guardian(s) _________________________________ Daytime Phone_________________ Cell Phone ________________Street Address ______________________________________ City ______________ __________State_______ Zip __________ Person(s) to be notified in an emergency if neither parent can be reached:
Name __________________________________ Relationship ____________________ Daytime Phone ____________________
Name __________________________________ Relationship ____________________ Daytime Phone ____________________
If a current or recent medical problem is likely to make a first aid situation particularly stressful for your child,
please note the details here:

Child’s Doctor _________________________________________ Phone _____________________Child’s Dentist _________________________________________ Phone _____________________ MEDICAL INSURANCE INFORMATION
Family medical insurance company_____________________________________ Policy or Group # __________________________
Child’s Medical Center # ________________________________________________
MEDICAL ALERTS/RESTRICTIONS: Please specify if your child has any of the following:
Dietary restriction________________________ ____________________________________________________________ Al ergies? _____________________________ ____________________________________________________________ Physical, emotional or learning needs?__________ ____________________________________________________________ Please list any medications that your child is currently taking:
Medication__________________________ Dose__________ Frequency__________ Name of licensed prescriber _______________
Medication__________________________ Dose__________ Frequency__________ Name of licensed prescriber _______________
NOTE: Please inform the camp if there are any changes in these listings during the summer.
IMMUNIZATION & PHYSICAL REPORT: Please include a copy of your child’s immunizations and the most recent physical exam report by May 1st.
Attached: Yes No If NO, it wil be sent or faxed on (date) ______________________________
EMERGENCY MEDICAL RELEASE: In case of medical emergency at any time during my child’s enrollment at Creative Arts at Park, I understand every
effort will be made to inform me (parent/guardian). In the event I cannot be reached, I hereby give permission to the physician selected by the Camp to hospi-
talize, secure proper treatment for, and order injection, anesthesia, or surgery for my child, as named on this medical form. I further agree to release and hold
harmless Creative Arts at Park and physician selected by the Camp from any liability arising out of such emergency treatment.
NON-PRESCRIPTION RELEASE: I give permission to the Camp nurse and/or other appropriate person to administer to my child the following non-
prescription medications (Tylenol, Motrin, Robitussin) in the event of headache, low-grade fever, complaints of minor aches, pains, or cold symptoms.
Parent/Guardian Signature _____________________________________________________ Date ___________________

Source: http://creativeartsatpark.org/ee-uploads/main-media-forms/CAAP_Medical_Form_2014.pdf

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