Child Application & Medical Form:
Please submit a separate form for each registered participant
(*) = Required
Child's Last Name(*):
Child's First Name(*):
Child's Date of Birth(*):
Island Mailing Address(*):
Off Island Mailing Address(*):
Parent or Guardian(*):
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(*):
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
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)(*):
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