ArtQuest Shadowing Emergency Card

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Please COMPLETELY fill out the following form with the student's emergency information. Once the form is submitted, a copy of your responses will be sent to your email address. Print them out and bring in with your student on the day of their shadow appointment.
* STUDENTS WILL NOT BE ALLOWED TO SHADOW WITHOUT THIS FORM AND A PARENT/GUARDIAN PRESENT.

AQ OFFICE USE ONLY:

ArtQuest Student- Docent Name: Last and First _______________________________________

ArtQuest Student- Docent ID#: __________________________________

Email *

Today's Date *

YYYY

Student Name: Last and First

Parent/Guardian Name: *

Check the ArtQuest Specialty you're Shadowing Today *

In Case of Emergency Call ( Primary Contact Name and Phone Number) *

In Case of Emergency Call ( Secondary Contact Name and Phone Number) *

Is the student covered by medical/hospital insurance? If yes, please provide your medical insurance info ( Kaiser, Sutter, etc) *

Emergency Information/Medical Issues/Allergies: *

PLEASE ENSURE THAT ALL INFORMATION IS ACCURATE AND COMPLETE BEFORE CLICKING "NEXT"

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