Child Application & Medical Form

Child Application & Medical Form:
Please submit a separate form for each registered participant

(*) = Required
Child's Last Name(*):
Child's First Name(*):
Child's Age(*):
Child's Date of Birth(*):
Child's Grade(*):
Island Mailing Address(*):
Off Island Mailing Address(*):
Parent or Guardian(*):
Home Phone(*):
Work Phone(*):
Cell Phone(*):
Email Address(*):
Alt Parent or Guardian(optional):
Alt Parent Home Phone:
Alt Parent Work Phone:
Alt Parent Cell Phone:
Alt Parent Email Address:
Household Members and Contact Numbers(*):
Emergency Contact(*):

Does your child have any physical restrictions? Allergies? Please specify including treatments, medications (*):

Please share a little bit about your child's behavior and ability to work with peers and adults in a highly creative environment (*):

On a scale of 1-10, how excited is the student to participate in the program (*):
Please list your child's swimming ability(*):
Non-swimmerBeginnerFairGoodRed Cross Cerficate Level

All children will be swim tested.

***IMPORTANT!***NO ATTENDANCE WITHOUT MEDICAL FORMS* Per VH Board of Health

  1. UPDATED within the year  IMMUNIZATION RECORD SIGNED AND DATED BY DOCTOR
  2. COMPLETED MEDICAL HISTORY FORM SIGNED AND DATED BY DOCTOR
  3. All forms and/or deposits may be mailed to
    Island Theatre Workshop
    PO Box 1893 VH 02568
    or just forms faxed to 508 627 4140 Attention: Stephanie Burke Thank you!


Permission to Administer First Aid

In the event of an emergency, injury or situation that requires medical attention I/We(Parent/guardian) ...give permission to the staff of Children's Theatre to administer the necessary first aid to (child's name): .

We also give permission to notify and utilize ambulance service as well as the services of Martha's Vineyard Hospital should that be deemed necessary.

Permission to Administer Medication 

I/We give authorization to the Camp Director of Children's Theatre to administer medication under the supervision of the Health Care Supervisor on site with detailed written instructions from a medical doctor. I understand that any and all medication will be kept in their original containers in a locked closet away from campers.

Signature for both of the above permission statements below:

Parent/Guardian signature (click in box to draw signature)(*):


Camper(s) Name(s)(*):
Date (click in box to draw date) (*):

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