To the best of my knowledge, my child,________________________ is in good
 health,  and I assume all responsibility for the health of my child.

In the event of an emergency, I give permission to transport my child to a hospital for
emergency treatment. I wish to be advised prior to any further treatment by the hospital
or doctor.

Parent/Guardian's Name: _________________________________________
Home Address:_________________________________Zip:____________
Home Phone: (    ) _______________ Business Phone: (     )______________


If you are unable to reach me, please contact:
Name:_______________________________________________________
Relationship to me or my son/daughter: ______________________________
Home Phone: (      )_______________Business Phone: (     )_____________

Please include a photocopy of your Insurance Card, front and back.
Insurance Carrier: _____________________ Policy Number:_____________

My son/daughter is under the care of a psychiatric/psychologist.
Name: ________________________ Phone Number: __________________
Please explain: ________________________________________________

My son/daughter is taking medication and will bring all medication with him/her and it will be clearly
labeled. My son/daughter is taking the following medication(s) and directions for taking this medication,
including dosage, frequency and storage are as follows: ________________________________
_____________________________________________________________

I hereby grant permission for non-prescription medication (such as cough drops, cough syrup, Tylenol,
etc.) To be given to my child if necessary. ___ Yes  ___ No.

I understand that aspirin will not be given to my son/daughter without my express permission: I grant
such permission __Yes, __No.

My son/daughter is allergic to the following:___________________________
My son/daughter's immunizations are current and up to date __Yes, ___No.
My son/daughter has the following limitations: _________________________
My son/daughter experiences homesickness, emotional reactions to new situations,
sleepwalking, fainting, bed wetting, etc. ____Yes ____No.
Please explain:_________________________________________________
____________________________________________________________

Signature of Parent or Guardian: ___________________________________
 

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