Child's Name Participants First & Last Name Pool Wading Pool Big Pool Child Lives With: Both Parents Mother Only Father Only Guardian Other… Enter other… Drop-off Time Pick-Up Time Do you give your child your permission to photo consent (for advertisement purposes on our social media account)? Yes No Alternate Emergency Contact Info: Emergency Contacts Name Emergency Contacts Phone Number Doctors Name: Doctors Name Doctors Phone Number: Do you have any special instructions for staff regarding the participant's heath care and/or diet? Does your child have any allergies to such things as drugs, food, insect stings, etc.? If so, please list, giving type of reaction, treatment given, etc. Please specify details of medication (over-the-counter and/or prescribed or treatment required for the above including transporting, administering and storing of medication while at playground). Will your child be on any medication during the summer months? Yes No If Yes, explain in detail: If your child uses a puffer/epi-pen/diabetic kit etc. they must carry them in a hip sack at all times. (NO EXCEPTIONS). Other medications can be stored in our medicine cabinet and arrangements must be made with our Head Supervisor regarding the administration of such medications (Tylenol/Advil/Ritalin, etc.). Extra epi-pens, puffers, etc., may also be stored in the office. Children are not allowed to take any medication without pre arrangements with the Head Supervisor, including Tylenol/ antihistamines etc. If you would like to add any additional information, please provide this below:
