Print and take a copy of this form. Also leave a copy at home with a friend or relative.

 

 

Personal Information

Last Name:

First Name:

Age:

Parent/Guardian:

Home address:

 

Group  1  2  3  4  5  6  7  8 (circle)

Counselor:

Home Phone:

Emergency Phone:

School:

Grade:

Do you need extended care? □yes  □no

Transportation to and from program: My child will

□walk      □be transported by parent  

□GrassRoots Bus circle one of the following:

Rand                 Grove                     Nishuane

Was child enrolled in last year’s program?

 

Do you have other children in Grass Roots program?

 

 

 

Has your child had a medical exam within the last 6 months?

Is your child in Good health?

Is your child restricted from any physical activities?

If yes, explain

 

Is there anything about your child’s health we should know?

If yes, explain

 

I hereby give my consent for emergency medical treatment.

□yes

□no

I hereby understand that in case of accident or personal injury, GrassRoots

Give my consent for my child to go on field trips and to participate in all

is only liable to the extent of its insurance coverage.  I also hereby

activities as designated and approved by the program director.


 

Indicate year of immunization against:

 

 

 

(DPT)Diptheria:

Tetanus:

  Polio:         

Measles:

Rubella:

Mumps:

Is your child allegic to peanuts or nuts?

□ Yes        □ No

Is Camper Susceptible to:
(Inidicate yes or no)

 

 

 

Fainting: □yes □no

Nose Bleeds: □yes □no

Convulsions □yes  □no

Motion sickness □yes □no

Eye and ear infections □yes □no

Foods to which child is allergic:

Any activity in which the child should NOT participate:

 

Is your child physically or mentally restricted or classified in any way?

□yes    □no

If yes, explain:

 

Does your child have disciplinary problems?

□yes    □no

If yes, explain:

 



*In order to meet all legal requirements, I hereby authorize representative of the Montclair Grass Roots Summer Program to give consent for any and all necessary emergency medical care for my child while said child attends the Montclair Grass Roots Summer Program.

 

Work Phone:

Signature of Parent or Guardian:

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