Children’s academy of fine arts, inc

Children’s Academy of Fine Arts, Inc. (CAFA) PARENTAL/GUARDIAN CONSENT AND MEDICAL AUTHORIZATION
Name of Child/Youth:_____________________________________________ Grade ______ Age_____ Address: _____________________________________________________________________________ Street/Apt Number City Zip Code Daytime Phone Number: _________________ Evening Phone Number: _________________ As the Parent/Legal Guardian of: __________________________________________________________ Child/Youth’s Name I understand that my child/youth will be participating in a number of activities at the CAFA program which carry with them a certain degree of risk. Some of the activities are art, stage craft and performance and sports. I consent for my child to participate in these activities. Please indicate any restrictions on your child’s/youth’s activities: _____I represent that my child/youth is physically fit and has the necessary skills to safely participate in these activities. _____I represent that my child/youth has restrictions on the following particular activities: _____I also understand and give consent for my child/youth to travel to and from these events in transportation provided by volunteer drivers. MEDICAL TREATMENT AUTHORIZATION It is my understanding that CAFA will attempt to notify me in case of a medical emergency involving my child/youth. If CAFA cannot reach me, then I authorize the church to hire a doctor or health-care professional, and I give my permission to the doctor, or other health-care professional, to provide the medical services he or she may deem necessary. I will pay for any medical expenses so incurred. I wil notify CAFA if I feel there are any health considerations that would prevent my child/youth’s participation in any of the CAFA activities. ALLERGIES OR OTHER HEALTH CONSIDERATIONS: Insurance Company:__________________________________, Policy/Group No:__________________ Signature of Parent or Guardian___________________________________________________________ PARENTAL/GUARDIAN CONSENT AND
MEDICAL AUTHORIZATION
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PARENT/GUARDIAN PERMISSION FOR
PRESCRIPTION AND OVER-THE-COUNTER MEDICATION CAFA is required to have written consent from a camper’s parent/guardian for each over-the-counter and prescription medication he or she takes. To permit the above mentioned camper to receive such medication, please initial next to its name. Tylenol/Acetaminophen________ Please list all prescription and over-the-counter medications the camper will take AND dosage information. The CAFA medical service technician must keep and dispense all medications. ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ SIGNED:________________________________________________Date___________________________

Source: http://www.cafakids.org/documents/CAFA%20Emergency%20Medical%20and-or%20Surgical%20Care%20V2%20Jun13.pdf