Mount Zion Albany GA - CAPS

Emergency Contact Form

Participants Last Name

Participants First Name

Parent / Guardian Name

Parent / Guardian Address

Numbers to call in emergency:

Parent place of employment

Employee Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Work Number

Doctor's Address

Emergency Medical Treatment: In the event of an emergency, I hereby give permission to transport my child to a hospital by car or ambulance for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, transport my child to:

List Name

Medications: My child is taking medication at present. My child will bring all such medications necessary, and such medications will be well labeled. Names of medications and concise directions for seeing that the child takes such medications, including dosage and frequency of dosage is as follows:

Check all that apply: (medications)

No medication of any type whether prescription or nonprescription may be administered to my child.

No medication of any type whether prescription or nonprescription may be administered to my child unless the situation is life-threatening and emergency treatment is required.

I hereby grant permission for nonprescription medication to be given to my child if they become ill with symptoms such as headache, vomiting, sore throat, fever, diarrhea such as aspirin, throat lozenges, and cough syrup.

Special Medication Information

Allergic reactions (medications, foods, plants, insects, etc.):

Vaccinations/Shots are up to date:

Yes

No

Most recent date of Tetanus Shot:

You should be aware of these known medical conditions of my child.

Parent Email address

Signature

C.A.P.S. Summer Enrichment Camp Application 2024

Student Information

School Information

Parent / Guardian Information

Student Interest (select 2 only)

Emergency Contact Form

Special Medication Information

About

Service Times

Follow Us