Health and Emergency Information/Procedure Form (IS183 Summer Art Camp)
Participant/Camper Information
Child Full Name *
Your answer
Age *
Your answer
Date of Birth *
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DD
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Sex *
Your answer
Pronouns
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Home Address *
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Known Allergies: *
Required
Please describe the allergy/allergies selected above. Include specific allergen and the reaction seen.
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If medical intervention is required for the above allergy/allergies, please list any allergy medication your child will bring to 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. *
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.
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Additional Participant Information/Restrictions (Please select all that apply). Has/Does this child... *
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:
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