Health and Emergency Information/Procedure Form (IS183 Summer Art Camp)
Child Full Name
Date of Birth
No Known Alleries
Please describe the allergy/allergies selected above. Include specific allergen and the reaction seen.
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.
Allergy Management: If your child has an anaphylactic allergy, please email a copy of the child's allergy action plan to
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
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.
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
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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