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Summer Art Camp Medical Form

Please fill out the entire form below. Form must be completed prior to the first day of camp.
Questions? Call Brett John Johnson, Studio Programs Manager of the Delaware Art Museum at 302.571.9590 ext. 551 or via e-mail at bjohnson@delart.org.
Session:
Participant's Name:
 Date of Birth:

Medical Information

Please complete the following immunization information for our records:
       
Month/Year Immunization    
DTP (Diptheria, Tetanus, Pertussis)
OPV (Polio/Oral) / IPV (Polio Injected)
HIB (Hemophilus Influenza)
MMR (Measles, Mumps, Rubella)
 

Camp staff is NOT permitted to dispense medication.

Due to food allergies, camp staff is NOT permitted to provide food or beverages (other than water) to camp participants. Parents/guardians must provide lunches and snacks for children.
I hereby certify that my son/daughter is fully capable of participating in this camp program.

Emergency Information

In case of emergency please contact:
Name:
 Relationship:
 Phone Number(s):
Or, if unable to reach the above person, please contact:
Name:
 Relationship:
 Phone Number(s):
List of people authorized to pick up your child:

In the event of an emergency, if I cannot be contacted, you have my permission to treat my child.

Policy Number:
   

 
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