Child Health Form – Glen Arbor Arts Center

Will you need to complete a health 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.

Email

This field is for validation purposes and should be left unchanged.

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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