The health history as listed below is correct and complete to the best of my knowledge. I give permission
for participation in all program activities except as noted. I understand that in the event my child requires
medical treatment while at DPAC, reasonable efforts will be made to contact me and the alternate contact person
listed. In the event of an emergency that cannot be handled by staff, I understand that my child will be
transported to the nearest hospital by private vehicle or by ambulance. I give permission to the facility to order x-
rays, routine tests or treatment; also to release any records necessary for insurance purposes and to provide
or arrange the necessary related transportation for my child. I hereby release the Dadeville Performing Arts
Center and all persons associated with the program from any liability associated with any accident, injury, or
disease (including COVID) of the person who is the subject of this form.
I authorize the nurse the task of assisting my child in taking the listed
medication. I understand that all medications will be administered according to the directions on the medication label. If
there has been a change, I must provide written documentation by the prescribing physician. I also authorize the nurse to
talk with the prescriber or pharmacist should a question come up about the medication.
ALL medication must be registered with the nurse. It must be in the original, unopened, sealed container and be properly
labeled with the camper’s name, prescriber’s name, date of prescription, name of medication, dosage, strength, time
interval, route of administration and the date of drug expiration when appropriate.
