Imaginers Summer Camp 24 Week 2

Imaginers, Week 2 - 6/24-6/28: I Have a Voice

Camper Information

Child's Name

First

Last

Parent/Guardian Name

First

Last

Email (Parent/Guardian)

Camper’s Age the first day of camp

Current Residence

Address Line 1

Address Line 2

City

State

Zip Code

Emergency Contact Information

Emergency Contact #1 (Parent or Legal Guardian)

First

Last

Phone (E Contact #1)

Emergency Contact #2 (Other than Parent Above)

First

Last

Phone (E Contact #2)

Primary Care Physician or other provider of medical care

First

Last

Phone (Primary Care Physician)

Health Information

Are there any health problems including physical, psychiatric, or behavioral problems of which we need to be aware?

No
Yes

You answered 'Yes' to the question above, Please explain.

Are there any medications, dietary restrictions, allergies, or special needs that we need to be aware of to ensure that your child’s camp experience is positive?

No
Yes

You answered 'Yes' to the question above, Please explain.

Immunization Infromation

Where do you currently reside?

WITHIN the United States, a United States territory, or the District of Columbia
OUTSIDE the United States, a United States territory, or the District of Columbia

Does the camper have any immunization exemptions because of a parental or guardian objection or medical contraindication?

No
Yes

You answered 'Yes' to the question above. Please list exemptions.

Attach record of vaccination or immunity on Department form MDH-896.

Click or drag files to this area to upload. You can upload up to 2 files.

You may upload .pdf, .jpg, or .webp files here. File may not exceed 2MB.

Medication Information

Please check NO or YES if your child will need to take ANY FORM OF MEDICATION (Including prescription medication or over the counter medication) during camp hours ONLY, including any prescribed EMERGENCY MEDICATION.

No
Yes

IMPORTANT:

You checked 'YES' above.

YOU MUST SUBMIT A MEDICATION ADMINISTRATION AUTHORIZATION FORM SIGNED BY A PHYSICIAN, PHYSICIAN ASSISTANT, or NURSE PRACTITIONER DUE May 31, 2024.

ALL MEDICATION ADMINISTRATION AUTHORIZATION Forms must be
completed and submitted by May 31, 2024. If this signed Medication Administration
Forum is not submitted to Art Works Now by May 31, 2024, your registration will be
canceled.

Parent or Legal Guardian’s Signature

To sign, type your full name above. This will be considered your signature on this document.