Test Emergency Medical Form

Emergency Medical And Disclaimer Form – K12 Gallery&Tejas

An Emergency Medical Form must be submitted for each child attending youth art camps. This form should be completed online or completed and returned to K12 Gallery & TEJAS prior to the start of the camp OR can be turned in when the participant checks in for his/her first day of camp.

Participant Information

Student's Full Name *

Date of Birth *

Grade *

City *

State *

Zip Code *

Parent / Guardian Information

Parent / Guardian #1 Full Name *

Parent / Guardian #2 Full Name

Contact Info for Guardian #1

Place of Work *

Email *

Cell Phone *

Work Phone

Home Phone *

Contact Info for Guardian #2

Place of Work

Email *

Cell Phone

Work Phone

Home Phone

Additional Emergency Contact: *

Relationship to Student *

Home Phone*

Cell Phone*

Additional Emergency Contact: *

Relationship to Student *

Home Phone*

Cell Phone*

Please indicate how your child will arrive/depart each day *Dropped Off & Picked Up by Parents/GuardiansDriving ThemselvesDropped Off & Picked Up by OtherWalking/BikingTaking the Bus

Name and phone numbers of people allowed to pick up your child.
Please be aware that ID must be provided at pick-up. *

Please fill in Name - Phone Number

Medical Information

Does the student have any physical, mental, developmental, or behavioral conditions that staff should be aware of? *YesNo

If Yes, please describe:

Will the student be taking medications while at K12 Gallery?YesNo

Will the student be administering their own medication?YesNo

Will the student need staff to administer a medication for them?YesNo

Please list all medications:

Medication

Dosage

Take at what times

Medication

Dosage

Take at what times

Please list whatever medications the student will need to carry due to any life threatening conditions (i.e. bee sting kits, inhalers):

Medication

Dosage

Take at what times

Medication

Dosage

Take at what times

Does the student have any allergies we should be aware of?*YesNo

Please list all allergies (and allergy related info you would like staff to be aware of):

Family Physician's Name:

Phone

I recognize and understand that there are certain inherent risks associated with participation in summer art camp. I fully accept and agree to assume full responsibility for all risks of injury, which include, without limitations, scrapes, bruises, cuts or other more serious injuries for the minor listed on this medical form. I release and discharge K12 Gallery for Young People, dba: K12 Gallery & TEJAS, it’s affiliates, officers, members, agents, employees, other participants and sponsoring agencies for any injury, loss or damage arising out of or related to participation in summer art camp. This waiver and release shall be binding and apply to all risks, known and unknown, even if resulting from negligent actions of other guests or employees of K12 Gallery for Young People, dba: K12 Gallery & TEJAS.

In the event of an accident, injury, or sudden illness, I give consent for my child to receive emergency medical treatment, including emergency medical transportation, by a healthcare professional.

I hereby voluntarily and knowingly authorize K12 Gallery & TEJAS the right to use all, or any part of artwork, photo documentation, or video filming.

Signature of Parent/Guardian *

Date: *

Test Emergency Medical Form

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341 S Jefferson St, Dayton, OH 45402 | 937-461-5149