Deerfield Community Center
Summer Day Camp
General and Emergency Information
*One form per child*
Birth Date: ______________________ Gender: _____________ Phone: ___________________
Parent/Guardian: ____________________________________________________________________
Home Address: _____________________________________________________________________
Email:________________________________________________________ Cell: ______________________
Email:________________________________________________________ Cell: ______________________
Child’s Physician/Clinic: ___________________________________ Phone: __________________
Clinic Address: _____________________________________________________________________
List any allergies or other necessary information needed about participant: ______________________
__________________________________________________________________________________
PERSON TO BE NOTIFIED IN CASE OF EMERGENCY WHEN
PARENT/GUARDIAN IS NOT AVAILABLE:
Name: ________________________________________ Phone: ____________________________
Address: ___________________________________________________________________________
IMPORTANT
I give my child, named above, permission to participate in all program activities, which pertain to his/her age group. In the event that I do not want my child to participate in activities, I understand that I must contact a staff person at the center. I also understand that if my child does not obey the center’s rules, he/she may be asked not to participate in activities.
Furthermore, in the event of an emergency, during which I cannot be contacted, I authorize you to call my doctor. If he/she cannot be contacted, I give my consent for my child to receive emergency medical treatment or care. I understand that a Deerfield Community Center staff will make every effort to contact me first.
X __________________________________________________ X __________________________________