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Medical Information Form


Child's Name (First) *
Child's Name (Last) *

Parent/Guardian Name 1 *
Lives in Home with Child*
Cell Phone *
Work Phone
Email *

Parent/Guardian Name 2
Lives in Home with Child
Cell Phone
Work Phone

In case of emergency, what is the best number to reach you?

Emergency Phone *

Emergency Contact Information: In the case of an emergency, we will first attempt to contact the parents/guardians. If they cannot be reached, the camp will contact the below authorized emergency contact. If I choose not to provide an emergency contact, I realize that if parents/guardians cannot be reached, ETC will not have a person selected by myself to contact.

Emergency Contact's Name *
Emergency Contact's Number *
Emergency Contact's Number
Relationship to Child *

Please list any other adult (other than parents/guardians listed above – both automatically have pickup authorization), who is allowed to pick-up the child from camp (including emergency contact.):  This field is required, if you have no additional authorized contacts, please enter N/A below.

Additional Authorized Contact *

Medical/Health Information: If child has medical concerns or allergies, please make sure to fill in all pertinent information below: (all fields are required, if no information is available, please enter N/A)

Medical Concerns or Allergies*
Current Medications *
Activities Child Should Not Participate in *
Physician *
Physician's Phone
Dentist *
Dentist's Phone
Insurance Carrier *
Preferred Local Hospital *

Pre/Post Care: Ensemble Theatre Company, Ltd does not provide pre/post care opportunities at this time. Please do not drop child off more than 15 minutes before the start of camp (9:00 am) in the morning. In the afternoon a pickup grace period of 15 minutes is allowed. After that grace period (4:15 pm) there will be a charge of $1.00 per minute, non-emergency related.

Statement of Accurate Information *

I certify that all of the above information is correct and accurate to the best of my knowledge. I have read and understand policies of Ensemble Theatre Company, Ltd.

Clicking the SEND button below acts as your signature for this form

Or click here to download the PDF, print, and bring it on the first day of camp.