Camp Information and Medical Form

* indicates required field

Parent/Guardian 1 Name*

Parent/Guardian 1 Phone*

Parent/Guardian 1 Email*

Parent/Guardian 2 Name

Parent/Guardian 2 Phone

Parent/Guardian 2 Email

Emergency Contact Phone*

Emergency Contact Email

Physician's Phone Number*

Does your child have any Medical Conditions (asthma, heart conditions, seizures, injuries, visual/hearing/speech concerns, etc.)?*

Yes No

Medical Conditions; If YES, please explain

Does your child require any Medications during camp hours?*

Yes No

*Wayne Art Center does not administer medication during the school day.

Medication; If YES, please explain

Does your child carry an EpiPen or other delivery devices?

Yes No

Does your child have any Allergies (food, insect, drug, latex, seasonal)?*

Yes No

Allergies; If YES, please explain

Does your child have Behavioral or Emotional needs WAC should be aware of?*

Yes No

Behavioral or Emotional needs; If YES, please explain

I hereby authorize emergency medical treatment for the above-named child in the event of any injury sustained at Wayne Art Center. I hereby authorize any health-plan-participating or non-participating physician, hospital or other health care provider to give emergency medical care and treatment to the above-named child at no cost to Wayne Art Center. The undersigned has read this medical authorization consent form and declares and affirms consent to the content herein stated. I assume all financial responsibility and waive all claims, or future claims, against Wayne Art Center for any injuries sustained by the above-named child.*

Yes - Authorize emergency medical treatment
No - Authorize emergency medical treatment

Instructions (No to Authorized Medical Treatment)

Signature for Authorized Medical Treatment*

Today's Date for Authorized Medical Treatment*

List all individuals authorized to pick your child up from camp.*

*Only individuals list here will be authorized to pick children up from camp.

Parent/Guardian Signature for Transportation Authorization*

I hereby grant permission for my child/my child’s artwork to be videotaped and/or photographed while participating in Wayne Art Center programs and activities. It is my understanding that these videos and photographs will be used, without obligation, only for Wayne Art Center promotional purposes, including print and digital publications/advertising, and may be shared with members of the local media for Wayne Art Center publicity purposes. In addition, I understand that local media may visit Wayne Art Center while my child is in attendance, and I grant permission for my child to be photographed/videoed by local media outlets featuring Wayne Art Center activities.*

Yes - Photography-Permission
No - Photography-Permission

Signature for Photography Release*

Today's Date for Photography Release*

Monday	9:00 am - 5:00 pm
Tuesday	9:00 am - 5:00 pm
Wednesday	9:00 am - 5:00 pm
Thursday	9:00 am - 5:00 pm
Friday	9:00 am - 5:00 pm
Saturday	9:00 am - 4:00 pm
Sunday	Closed

wayne art center

Camp Information and Medical Form

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