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.