CAPA ARTS CAMP HEALTH AND EMERGENCY FORM 2018

Student’s Name _________________________________ Grade ________

Address __________________________________________________

Home Phone _______________________________________

Day of event emergency contact (parent/guardian) ____________________________

Relationship to student ___________________________

Phone number of contact ______________________________

Important Health History:

Is your child subject to any of the following: Ear problems, fainting spells, asthma attacks, convulsions, seizures

Limitation of physical activities (if yes, please explain)

Food Allergies

Is your child allergic to any medications?  YES   NO   If yes, which meds?

Does your child have any special health needs/food allergies? YES   NO

If yes, please explain here:

_______________________________________                              ___________________

Name and Signature of Parent/Guardian                                   Date

Livonia Public School’s district policy does not permit us to administer ANY medication without your physician’s approval and your signature per the medication authorization form; available in the principal’s office. This includes aspirin, Tylenol, Motrin, Advil, Albuterol inhalers). If you feel that medication may be necessary during the course of the workshop day, please have the form filled out, signed and with medication to be handed to the appropriate CAPA staff member at the time of registration. Thank you.

CAPA Performing Arts Camp

Saturday, February 24, 2018 at Madonna University from 11:00-4:00

Applications are due by Friday, January 26, 2018

($25 cash or check made out to Churchill High School)

Student Name: _________________________________    Grade: _______

School: ___________________________

Phone Contact name and number: ________________________________________

Address: ____________________________________________________

E~mail address (please print legibly) _____________________________________________

T~shirt size (adult sizes):   S          M         L          XL        XXL

Areas of interest: ACTING    VOCAL      DANCING

If you are in 8^th grade and using camp as your audition into CAPA, please let us know at check in!

Any food allergies? If yes, please list allergies:

Workshop Rules

1.     No student should be in the hallways or bathrooms without supervision.

2.     Mentors will escort students to appropriate rooms.

3.     Attendance will be taken in every session after breaks.

4.     CAPA will provide snacks throughout the day.

5.     In the event of an emergency, immediately find a CAPA staff member or volunteer (parents/guardians of the participants must be available by phone during the house of the camp)

6.     Staff will stay with students until they are picked up at the end of the day, 4:00. A late fee of $5.00 will be charged for every 15 minutes after the designated pick up time of 4:00.

7.     Parent/Guardian must check their student in and out of the camp at the registration table before dropping off or picking up their student. Registration/check in begins at 10:30 a.m.

8.     Students will leave all valuables, including cell phones, at home. Phone service is available for students in case of emergency or to call home for a pick up.

9.     By signing below, both student and parent/guardian agree to the above workshop rules and verbal directions given by the camp staff.

__________________________________    _____________________________

Student Signature                                       Date

________________________________        __        _______________________________

Parent/Guardian Name                              Parent/Guardian Signature   

Please send health and registration forms with a payment of $25 by January 26, 2018 to:

Ms. Hillman, Director of CAPA                 Forms:

Churchill High School                                 1. Registration  ____

8900 Newburgh Road                                 2. Health and Emergency _____

Livonia, MI 48150                                        3. Full Payment for Workshop

                                                                    

Still glowing over the musical we wrapped in December! CATS was a labor of love and an unforgettable "memory!"