Student's Full Name *

Gender *

Date of Birth *

Grade is your child finishing May 2021 *

Describe the support your child receives at school (educational assistant, one-on-one support, etc). If none, put NA. *

Information about Hearing Level, Mode of Communication, Listening Devices if applicable. *

SDSD Outreach Consultant Name *

Hands in Motion camp runs from July 5 - July 30, Mondays through Fridays, 8:30 am - 11:30 am CST. Please list the dates your child will be attending. *

Parent/Guardian's Name(s) *

Parent/Guardian's Phone Number(s) (specify cell or home phone numbers) *

Parent/Guardian's Email Addresses *

Parent/Guardian Work Phone Numbers

Authorized Pick ups (Include Names, Relationships, and Cell phone Numbers *

Current Health Concerns (if none, put NA) *

Allergies (if none, put NA) *

Immunizations Up to Date *

Primary Physician's Name, Address, Phone Number *

Consent for Medication Treatment. The law requires parental permission for medical or surgical treatment of a minor. The hospitals in our area have a similar requirement, relative to admission and treatment. In an emergency, if such treatment becomes necessary, every effort will be made to obtain your consent before treatment. In the event that you are temporarily unavailable, your prior consent to treatment is important to avoid unnecessary delay. However, no surgical procedure will be performed without your knowledge and consent, with the exception of a lifesaving emergency. I understand the considerations set forth above, and hereby consent to and authorize any physician and any hospital involved to perform such emergency medical or surgical treatments as may be deemed necessary for my son / daughter. Please type your name and date if you are in agreement. *

Please mark preference in Hospital *

Travel - I authorize Hands in Motion staff to provide my child with transportation to recreational and educational activities. These include community based educational activities (including field trips), sports and recreational activities. I hereby consent for my child to leave Hands in Motion location (on foot) with other students and staff. *

Activity- I give my permission for my child to attend and participate in various activities arranged and carried out by numerous organizations here in the community. Hands in Motion staff will accompany students to these activities. *

Media - I hereby authorize Hands in Motion staff to use my child's picture in any media in which may appear. It is understood that Hands in Motion/SDSD will only use these materials for educational purposes and news releases. Examples: SDSD Newsletter, SDSD and Hands in Motion Facebook pages, SDSD website, etc. *

Liability Statement - I will not hold individual staff members, volunteers, or South Dakota School for the Deaf or Hands in Motion responsible for accidents, injuries, or harm occuring to my child while he / she is attending Hands in Motion (on and off site). I am aware that failure of my child to abide by all rule and regulations may be cause to deny off site privileges. If in agreement, type your name and date. *