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IS183 Young Artist Health Form
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* Indicates required question
Student/Camper Information
Child Full Name
*
Your answer
Age
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Sex
*
Your answer
Pronouns
Your answer
Home Address
*
Your answer
Known Allergies:
*
No Known Allergies
Food
Medicine
Environmental
Other:
Required
Please describe the allergy/allergies selected above. Include specific allergen and the reaction seen.
Your answer
If medical intervention is required for the above allergy/allergies, please list any allergy medication your child will bring to class/camp. Include medication name, amount/dose given, and when it is given.
Your answer
Allergy Management: If your child has an anaphylactic allergy, please email a copy of the child's allergy action plan to
lucie@is183.org
.
*
This child does not have any known anaphylactic allergies.
This child has been trained to administer his/her own EpiPen.
This child recognizes the onset of an allergic reaction and can notify a staff member if symptoms occur.
This child does NOT recognize and report the onset of an allergic reaction. Call the Executive Director at 413.298.5252 x101
Required
Please list any other medications, including over-the-counter or non-prescription drugs, taken routinely. Include medication name, amount/dose given, and when it is given.
Your answer
Additional Participant Information/Restrictions (Please select all that apply). Has/Does this child...
*
wear glasses/contacts/protective eyewear?
ever been stung by a bee?
ever have need for an aide at school?
used an individualized education plan (IEP) during the previous school year?
speak a primary language other than English?
have any dietary restrictions?
None of the above
Required
If yes to any above, please elaborate if necessary below. Please also use this space to explain any other physical, mental, emotional, or social health concerns that staff should be aware of:
Your answer
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