Emergency Form - Philly Inmovement printable pdf download

Emergency Form

A completed form MUST be received for your child to attend any drop-off class, vacation camp,

summer camp or afterschool program. Forms are valid for one year, after which a new form will be

required. If information should change before a year is up, please complete a new form. Thanks!

Please bring this form when you drop-off your child off, on the first day of their program. Please do

not email. If you must mail ahead, mail to our administrative address: 514 Bainbridge Street,

Philadelphia, PA, 19147 for programs at all locations.

Child’s name: ____________________________________________________________________ Date of Birth: ____/ ______ / ___________

In the event of an emergency, we will contact you on any/all phone numbers provided at the time of registration (If you think those numbers need

updating, please login and review your online account). If you are unreachable, we will contact the following people, in the order they are listed:

1. Name:__________________________________________ Phone #: ____________________ Relationship: ______________________

2. Name:__________________________________________ Phone #:_____________________ Relationship: ______________________

Your child’s doctor’s name, address & phone number: __________________________________________________________________________

______________________________________________________________________________________________________________________

Does your child have allergies? Please describe. ________________________________________________________________________________

_______________________________________________________________________________________________________________________

If you answered YES above, then please read and sign below. If not, skip to the next question.

Epi-pens & Inhalers: Philly Art Center representatives will administer Epi-Pens, Benedryl & Inhalers in case of emergencies ONLY. You

must provide Epi-Pen, possible Benadryl & inhalers in labeled bag with clear directions included. Your signature is required below for this

option.

I hereby authorize Philly Art Center and/or its representatives to administer an Epi-Pen, Benadryl and/or Inhaler to my child named

above, according to the written direction included with the Epi-Pens/Inhalers that accompany my child to the Art Center.

Guardian’s Signature:______________________________________ Print name: ___________________________________________

Does your child have any medical or emotional concerns or diagnosis?_____________________________________________________________

_______________________________________________________________________________________________________________________

Does your child have any learning needs? ____________________________________________________________________________________

_______________________________________________________________________________________________________________________

We pay close attention to each child’s social/emotional and general needs. Please tell us anything else about your child that would be helpful to

teachers and staff to help make your child’s time with us awesome.

________________________________________________________________________________________________________________________

I, parent/guardian of the above named child, hereby give my approval for his/her participation in any and all Philly Art Center, Art Mark LLC, activities including field

trips off-site, by foot and/or by public bus. I authorize Philly Art Center, Art Mark LLC, and its authorized representatives, to take whatever actions it may consider

warranted under the circumstances regarding my child’s health and safety and I fully release the Philly Art Center, Art Mark LLC and its authorized representatives

from any liability for such circumstances or actions as may be taken in connection therewith. I authorize the Philly Art Center, Art Mark LLC, and its authorized

representatives, at its discretion, to place my child, at my expense and without further consent, in a hospital for medical services and treatment, or if a hospital is not

readily available, to place my child in the hands of a licensed medical professional for treatment. I authorize Philly Art Center, Art Mark LLC, to publish photos and

videos of my child in promotional materials and on social media.

Guardian’s Signature:_____________________________________________________________________ Date: ___________________________

Print Name: ______________________________________________________________________ Relationship: ___________________________