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: ___________________________