"Drop Off" Program Form
For programs where parents do NOT stay. Please fill out a separate form for each participant. This only needs to be completed 1 time per calendar year. If something changes before then, please let us know!
Participant's First Name
Participant's Last Name
Participant's Birthdate
Address
Parent/Caregiver 1
Cell phone of Parent/Caregiver 1
Parent/Caregiver 2
Cell phone of Parent/Caregiver 2
Email
Emergency Contact (If parent cannot be reached)
Emergency Contact Phone Number
Relationship to participant
Allergies, Diagnosis, Special Health Considerations, or Physical Accommodations
Any challenging behaviors we should be aware of:
What techniques help with these behaviors at home?
Please list any medications your child is taking.
Does your child have medical emergencies that require a plan of action(for ex. seizures, bee sting
yes
no
If yes, please indicate what it is and what should be done if it were to happen.
Hospital Preference
Physician's Name
Physician's Number
Insurance Company
Policy Number
If parent/caregiver cannot be reached, I authorize all medical treatment and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment.
Print Name
Your Signature
Clear
Date
Anything else you would like to share:
Send