CAPS_App

Parent/Guardian Information

Parent First Name

Parent Last Name

Parents Home Phone

Emergency / Contact Phone

Does your child need to be picked up from school?

Yes

Does the CAPS Tutorial have permission to take and use photos of your child for the purpose of the programs posting on social media.

Yes

Emergency Contact Form

Participant's First Name

Participant's Last Name

Date of Birth

Parent/Guardian First Name

Parent/ Guardian Last Name

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Number to Call in Emergency:

Parent/Guardian place of employment:

Address (Street, City, State)

Work number

Family Doctor

Family Doctor Number

Family Doctor Address

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:

Medications:

Check all that apply:

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.

Allergies: Special Medical Information: Allergic reactions (medication, foods, plants, insects, etc.)

Vaccinations/Shots are up to date:

Most recent date of tetanus shot

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

Signature

Date of signature

C.A.P.S. Tutorial Application

2025

Student Information

School Information

Parent/Guardian Information

Emergency Contact Form

C.A.P.S. Tutorial Application2025

Student Information

School Information

Parent/Guardian Information

Emergency Contact Form

C.A.P.S. Tutorial Application

2025