Parent/Guardian Name
*
First Name
Last Name
Relationship to Student
*
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone Number (Primary)
*
(###)
###
####
Phone Type
*
Parent/Guardian Phone (Secondary)
(###)
###
####
Phone Type
*
Parent/Guardian Email
*
Emergency Contact Full Name
*
First Name
Last Name
Emergency Contact Phone
*
(###)
###
####
Relationship to Student
*
Emergency Contact Email
*
Child's Name
*
First Name
Last Name
Child's Birthday
*
MM
DD
YYYY
If your child any diagnosed learning disabilities or physical disabilities requiring accommodations, please list those below.
*
Is there anything you would like us to know about your child?
*
Child’s Primary Care Physician Name
*
To be used in cases of emergency.
First Name
Last Name
Child’s Primary Care Physician Practice
*
Child’s Primary Care Phone
*
(###)
###
####
Does your child have health conditions of any kind (including physical, psychiatric, and behavioral) of which we should be aware?
*
If you responded yes to the previous question, please list and/or explain here:
Are there any medications, dietary restrictions, allergies, or special needs that we need to be aware of to ensure that your child’s camp experience is positive?
*
If you responded yes to the previous question, please list and/or explain here:
Your child is covered by family medical/hospital insurance
*
Insurance Company
Policy ID Number
Subscriber Number
Insurance Company Phone Number
In emergency situations, I hereby authorize Elevated Learning Solutions, LLC to seek the necessary medical care from my child, including treatment by an EMT and/or hospitalization. Elevated Learning Solutions, LLC will attempt to immediately contact parents/guardians or designated emergency contacts in this situation. If I (or my designated contact) cannot be reached, I give permission to an EMT and/or physician to provide appropriate medical treatment for my child, including but not limited to X-rays, testing, anesthesia, injections and surgery. I authorize Elevated Learning Solutions, LLC to provide necessary medical attention to my child until an EMT or ambulance arrives. I also authorize routine treatment and first-aid in non-emergency situations. I understand that the Elevated Learning Solutions staff members are not licensed medical professionals, and cannot administer any medical care beyond basic first aid. I understand the information on this form will be shared on a “need to know” basis with Elevated Learning Solutions, LLC staff.
*
First Name
Last Name
*
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