CAPA Arts Camp: Health & Emergency Form 2017



Student’s Name:__________________________________________ Grade ______


Home phone:____________________________________________

Day of event Emergency Contact (parent/guardian): ________________________________

Relationship to student: __________________________________

Phone: _______________________________

Designated Adult for student pickup (if other than above): _______________________

Relationship to student: ______________________________________

Health History

Is your child subject to any of the following: Ear problems, Fainting spells, Asthma attacks, Convulsions

Limitation of physical activities (if yes, please explain):





Food Allergies

Is your child allergic to any medications? Yes    No    Medication

Does your child have any special health needs/ food allergies? Yes    No If yes, please explain:





Name of Parent/Guardian Signature of Parent/Guardian Date



Livonia Public School’s district policy does not permit us to administer ANY  medication without your physician’s permission and your signature per the medication authorization form; available in the Principal’s office (this includes aspirin, Tylenol, Motrin, Advil, Albuterol inhalers). If you feel that medication may be necessary please have the form filled out, signed, and with accompanying medication to be handed to the appropriate CAPA staff at time of registration. Thank you.