2024 Emergency Information Form

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**Your child's spot in camp will not be secured until all registration forms are completed.**

Email *

Record my email address with my response

Parent Email *

Last Name of Camper *

First Name of Camper *

Birthdate *

YYYY

Parent/Guardian Names *

Daytime Phone

Please list a phone number where you can be reached during camp hours.

Emergency Contact

Please list the name of someone to contact if we are unable to reach you. Please name someone who knows the camper well, and can assist in reaching the parent/guardian.

Phone Number of Emergency Contact *

Additional Emergency Contact *

Phone Number of Additional Emergency Contact *

Does your child have any allergies or chronic illness? *

Yes

If yes, please indicate the type of illness, allergy, reaction, and/or any special instructions we need to be aware of.

If your child carries and inhaler, or keeps allergy remedies on their person/backpack, please specify the remedy and where it is kept.

Is your child taking any medication during our regular camp day? *

Yes

If yes, please indicate proper names of medications dosages, and reason for taking.

Does your child have permission to self medicate? *

Yes

If your child has permission to self-medicate, please specify which medications:

Does your child have any other health issues we should be aware of? *

Yes

If yes, please describe.

Phillipsburg Area Summer Youth Theatre wants to give each child the best experience possible. If your child has any physical and/or emotional limitations, please let us know in the space provided below. This information will be kept in strict confidence, but will greatly assist us in coaching your child to the best of their ability, and will also help us to meet their individual needs.

Medical Release (Please sign name below)

This health history is correct and accurately reflects the known health status of the amed camper. The camper described has permission to participate in all camp activities except as noted by me and/or and examining physician. I give permission to camp staff to provide routing health care; to administer prescribed or over the counter medications as prescribed; and to provide or obtain emergency care an dtransportation for th ecamper if needed. I give permission to the physician selected by the camp to order x-rays, test, and treatment related to the health of my child, both for routing health care and in emergency situations. If I cannot be reached in an emergency, I give my permission to the physician to to hospitalize, secure proper treatment for, and order and administer medication, injection, anesthesia, x-rays, special procedures, or surgery for this child, if deemed medically necessary. I understand that I am responsible for the cost of any medical care or prescriptions my child requires. I understand that information on this form will be shared on a need to know basis with camp staff.

Waiver (Please sign name below:

I/we hereby waive and release Phillipsburg Area Summer Youth Theatre, Inc. the instructors, directors, and employees from any and all liability for any injurt or illness for the aforementioned cast or crew member in any activity in this theatre or any other activity sponsored by the Phillipsburg Area Summer Youth Theatre, Inc.

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