Child Health Form GAAC requires one completed health and emergency contact form per child that attends any GAAC class or camp. Each health form will be kept on file for one year and can be used for multiple classes or camps during that period. Will 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 InformationChild Name*(Required) First Last Birthday*(Required)Emergency Phone*(Required)Home Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Section 2 - Parent/Guardian Contact InformationParent/Guardian #1 Name*(Required) First Last Parent/Guardian #1 Relationship to ChildParent/Guardian #1 PhoneParent/Guardian #2 Name First Last Parent/Guardian #2 Relationship to ChildParent/Guardian #2 PhoneSection 3 - InsuranceIs the child covered by family medical/hospital insurance?*(Required) Yes No Insurance Carrier NamePolicy NumberGroup NumberPolicy Holder’s NameRelationship of Policy Holder to ChildSection 4 - AllergiesDoes 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).AllergiesList all allergies. Describe reaction and treatment.Section 5 - OtherChild HealthList any special health conditions, prescription or over-the-counter medications, and physical activities to be limited or restricted.Child Pick-UpList all additional adults who are able to pick-up your child from art class.Additional InformationIs there any additional information you would like to share about your child to ensure a wonderful class experience? Section 6 - AuthorizationPhoto 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.CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
