Child Health Form – Glen Arbor Arts Center

GAAC requires a completed health and emergency contact form for each child that attends any GAAC class or camp. Health and emergency contact forms are kept on file for one calendar year and can be used for multiple classes or camps during that period.

Do you need to complete a health and emergencey contact form?
- no
- yes
Please fill out this form as completely as possible. If you need to complete a health form for more than one child, you will need to exit this page and come back after submitting to refresh the form. All required fields are marked with *.

This form will be kept confidential and on file for use by our staff or emergency medical personnel. Thank you!
Section 1 - Basic Child Information
Child Name*
(Required)
First Last
Birthday*
(Required)
Emergency Phone*
(Required)
Home Address
Street Address City State ZIP Code
Section 2 - Parent/Guardian Contact Information
Parent/Guardian #1 Name*
(Required)
First Last
Parent/Guardian #1 Relationship to Child
Parent/Guardian #1 Phone
Parent/Guardian #2 Name
First Last
Parent/Guardian #2 Relationship to Child
Parent/Guardian #2 Phone
Section 3 - Insurance
Is the child covered by family medical/hospital insurance?*
(Required)
- Yes
- No
Insurance Carrier Name
Policy Number
Group Number
Policy Holder’s Name
Relationship of Policy Holder to Child
Section 4 - Allergies
Does the child have any allergies?*
(Required)
- Yes
- No
Please note: a limited amount of medication for life threatening conditions should be carried by your child (i.e. bee sting kits, inhalers).
Allergies
List all allergies. Describe reaction and treatment.
Section 5 - Other
Child Health
List any special health conditions, prescription or over-the-counter medications, and physical activities to be limited or restricted.
Child Pick-Up
List all additional adults who are able to pick-up your child from art class.
Additional Information
Is there any additional information you would like to share about your child to ensure a wonderful class experience?
Section 6 - Authorization
Photo Consent
I, parent/guradian #1 (as indicated in this form), give the Glen Arbor Arts Center permission to use my child’s photograph publicly to promote its programming. This includes printed publications, online publications, presentations, websites and social media. I also understand that no royalty, fee or other compensation shall become payable by reason of use.
General Consent*
I, parent/guradian #1 (as indicated in this form), give permission for my child to engage in all prescribed class activities except as noted. The information provided on this form is accurate to the best of my knowledge. I have indicated any special health conditions, including required medication and activity limitations which should be known to the GAAC staff and medical personnel. I am aware of and accept the risk inherent in the program activity. I give consent in advance for medical treatment at an appropriate medical facility and authorize the transfer of my child to any medical facility that is reasonably accessible in case of illness or injury. I hereby agree and promise that I will not hold the Glen Arbor Arts Center, its staff, or volunteers responsible for any loss, damages, or personal injuries that may occure as a result of participation.
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Comments
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Section 1 - Basic Child Information

Section 2 - Parent/Guardian Contact Information

Section 3 - Insurance

Section 4 - Allergies

Section 5 - Other

Section 6 - Authorization

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