health/emergency/permission form

no. andover historical society summer programs

Please submit this form for each child no later than July 20, 2018 for the Adventures in Time program.

Summer Program Health/Emergency/Permission Form
PARTICIPANT INFORMATION
Name of Child *
Name of Child
PARENT/GUARDIAN
Name
Name
Address
Address
Cell Phone
Cell Phone
Home Phone
Home Phone
Work Phone
Work Phone
HEALTH & EMERGENCY INFORMATION
Child's Physician *
Child's Physician
Physician Phone *
Physician Phone
Name of Insured Party
Name of Insured Party
Emergency Contact Person *
Emergency Contact Person
Daytime Phone *
Daytime Phone
HEALTH INFORMATION FOR CHILD
Does the Child have any Allergies?
Is the Child Current with all Immunizations? *
Check if the Child has any of the following conditions *
Are there any reason why child needs to restrict physical activity? *
Will the child require any medications? *
Parents or Guardians are responsible for administering any and all medications.
If we are unable to reach you in the case of emergency, do you authorize staff to arrange treatment for your child? *
Parent/Guardian Signature
Parent/Guardian Signature
Date
Date
FIELD TRIP PERMSSION
The program includes 1-2 half day field trips during the 4-day program. Location(s) to be announced.
Do you grant permission for the child to participate in field trips? *
If "NO", your child can not report for that session and no credit will be given.
PHOTOGRAPHY PERMISSION
Do you grant permission for your child to be photographed for use in Historical Society publicity, including but not restricted to its website, Facebook pages, local newspapers and the websites of the grant makers for this program? *
OTHER INFORMATION
Is there any other information we should know about your child? *
Please hit the "SUBMIT" button to transmit the Form. We will contact you if we have any questions or need further clarification.
 

978-686-4035

North Andover Historical Society
153 Academy Road
North Andover, MA 01845

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