Name of Participant/Participants*

Participant's Birthdate*

Participant's Pronouns*

Name of Parent 2

Phone Number of Parent 2

Name of Additional Person Authorized to Pick Up Participant

Telephone Number of Additional Authorized Pick-Up Person

Emergency Contact Name*

Emergency Contact Phone Number*

Name of Primary Care Doctor*

Phone Number of Primary Care Doctor*

Allergies*

Please list and explain allergies

Is the camper up to date on all immunizations?*

Significant medical history (surgery, injuries, serious illness):

List any medical problems (asthma, seizures, headaches):

List any learning challenges:

List medication taken:

In an emergency does this child require additional assistance (more than other children of the same age or in the same group) to evacuate?*

I consent to the use of sunscreen for my child.*

My child has permission to ride the TCAT bus or walk to planned field trips. I give my child permission to participate in all field trips.*

I give CSMA permission to take photographs, recordings, or videos of me/my child as we participate in CSMA activities; and to use such images, recordings, and content for purposes related to CSMA’s mission, including marketing. This permission is given without expectation of payment or other compensation at any time, and the released material shall be the property of the Community School of Music and Arts. This consent includes, but is not limited to: (a) Permission to photograph, film, interview, record, or make a video of me/my child; and (b) Permission to use, reuse, modify, or publish photographs, films, tapes, digital files, recordings, and any derivative works, in part or in whole, and in any format or media, including the internet, for purposes related to CSMA’s mission. To opt out of the Photo, Video, and Recording Release at any time, please contact the CSMA office.*

Name of Medical Insurance Company*

Medical Insurance Policy Number*

I give my consent for my child to participate in the CSMA Camp and agree to terms listed above.*