All Bright Club / Bright Start/Camp “EXPLORE!”
(also Art Studio 505 and Dance Studio Debut ABC)
CHILD REGISTRATION, MEDICAL & EMERGENCY FORM
CHILD INFORMATION
First: ____________________________ Middle: __________________________ Last:
____________________________
Gender: ☐ Male ☐ Female
Grade: _______ Birth date: //____
Street Address:
______________________________________________________________________________
_______ Town/City: __________________________ State: ______ Zip code: ___________
Child’s Home Phone: _______________________
PARENT/GUARDIAN — CONTACT INFORMATION
Parent/Guardian #1
Name (First / Last): ___________________________________________________
Title: ☐ Ms. ☐ Mrs. ☐ Mr. ☐ Other: _____________
Street Address:
_____________________________________________________________________________
_______ Town/City: __________________________ State: ______ Zip Code: ___________
Home Phone: __________________ Work Phone: __________________ Cell Phone:
__________________ Fax: __________________ Email: _________________________________
Occupation: _________________________________ Employer:
_________________________________ Parent/Guardian #2
Name (First / Last): ___________________________________________________
Title: ☐ Ms. ☐ Mrs. ☐ Mr. ☐ Other: _____________
Street Address:
_____________________________________________________________________________
_______ Town/City: __________________________ State: ______ Zip code: ___________
Home Phone: __________________ Daytime Phone: __________________ Cell Phone:
__________________ Fax: __________________ Email: _________________________________
Occupation: _________________________________ Employer:
_________________________________ EMERGENCY CONTACT INFORMATION — ALTERNATE
PICKUP / RELEASE
Emergency Contact #1
Name (First / Last): ___________________________________________________
Home Phone: __________________ Work Phone: __________________ Cell Phone:
__________________ Email: _________________________________ Relation to child:
_________________________________ Emergency Contact #2
Name (First / Last): ___________________________________________________
Home Phone: __________________ Work Phone: __________________ Cell Phone:
__________________ Email: _________________________________ Relation to child:
_________________________________ Important Notice:
In the event of an emergency, if none of the parents or emergency contacts can be reached within 10 minutes,
we will call 911.
AUTHORIZED PICKUP LIST
(Individuals, in addition to parents/guardians, permitted to pick up your child)
1.
2.
3.
MEAL INFORMATION (ADDED SECTION)
Child’s Meal Information / Notes:
Food Allergies:
________________________________________________________________________________
_______ Dietary Restrictions:
____________________________________________________________________________
______ Special Instructions (snacks / lunch):
____________________________________________________________________
Lunch Provided By: ☐ Parent ☐ Program ☐ Other: ____________________
Permission for occasional treats (events/celebrations): ☐ Yes ☐ No
MEDICAL RELEASE INFORMATION
Insurance Information
Insurance Provider: ___________________________________________________
Policy Number: _________________________________
Primary Physician
Physician Name: _____________________________________________________
Address:
______________________________________________________________________________________
_____ Phone: _________________________________ Hospital Preference:
_________________________________ Medical Problems
Please list any medical problems, including those requiring maintenance medication (e.g., Diabetes, Asthma,
Seizures).
1. Medical Problem: __________________________________ Required Treatment:
_______________________ Should Paramedic be called? ☐ Yes ☐ No
2. Medical Problem: __________________________________ Required Treatment:
_______________________ Should Paramedic be called? ☐ Yes ☐ No
3. Medical Problem: __________________________________ Required Treatment:
_______________________ Should Paramedic be called? ☐ Yes ☐ No
Medication / Illness
Is your child presently being treated for an injury or sickness, or taking any medication? ☐ Yes ☐ No If yes,
explain:
______________________________________________________________________________
_______ Purpose Statement
The purpose of the above listed information is to ensure that medical personnel have details of any medical
problem which may interfere with or alter treatment.
EMERGENCY MEDICAL CONTACTS
In case of medical emergency contact:
Contact #1 — Name: __________________________ Phone #: _______________________ Relationship:
___________________
Contact #2 — Name: __________________________ Phone #: _______________________ Relationship:
___________________
Contact #3 — Name: __________________________ Phone #: _______________________ Relationship:
___________________
MEDICAL AUTHORIZATION — PART 1
I understand that I will be notified in the case of a medical emergency involving my child. In the event that I
cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the
event my child is injured or becomes ill.
Parent’s/Guardian’s Initials: ______________________
MEDICAL AUTHORIZATION — PART 2
I understand that All Bright Club / Bright Start/Camp “EXPLORE!” will not be responsible for the medical
expenses incurred, but that such expenses will be my responsibility as parent/guardian. Parent’s/Guardian’s
Initials: ______________________
GENERAL LIABILITY & PHOTO CONSENT
All Bright Club / Bright Start/Camp “EXPLORE!” and its co-organizers are not responsible for lost or damaged
personal property. All scheduled events are subject to change. No fees will be refunded or transferred unless a
child is unable to participate due to an accident or illness per physician orders. Children’s photos and quotes
may be used for publicity purposes.
In case of an emergency, and if a family physician cannot be reached, I hereby authorize my child to be treated
by Certified Emergency Personnel (EMT, First Responder, and/or Physician). GUARDIAN SIGNATURE
(SECTION 1)
Guardian Signature:
__________________________________________________________ Date:
__________________________
Printed Name of Parent/Guardian: _______________________________________________
CONSENT (SECTION 2 — FULL CONSENT)
In case of medical emergency or general medical care, I give consent for medical treatment for the above
named camper by authorized personnel. The program carries secondary insurance. I understand that the
above named camper will only be released to the names listed below, and updates may be made at
registration.
I certify that my child has my permission to attend and participate in all activities. I authorize All Bright Club /
Bright Start/Camp “EXPLORE!” to use my camper’s picture or testimony in any promotional material (web,
print or media).
Guardian Signature:
__________________________________________________________ Date:
__________________________
Printed Name of Parent/Guardian: _______________________________________________