Summer Permission Form

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Summer Permission Form

Summer Permission Form

Child's Full Name *

First

Last

Date of Birth

Address

Cell Phone

Swim Permission

Excellent Swimmer
Good Swimmer
Fair Swimmer
Poor Swimmer

He/She is an

Field Trip Permission *

I grant permission

I grant permission to AEC to take my child on all field trips sponsored by AEC by any means of transportation that is provided. Please note: On scheduled field trip days, there will be no alternate program for children to attend other than the field trip.

Medical Information

Please list any allergies (medical, food, insect toxin, other) that your child suffers from

History of

Asthma
Convulsions
High Fever
Diabetes

Does the child have any special needs?

Any conditions that the child is medicated for?

*If any medication, either prescription or over the counter, is coming with the child, it must be accompanied by a physician’s note. The note should state the child’s name, the drug name, amount given, and time to be given. Prescriptions with “over the counter” medications MUST be in original, labeled bottles or containers. For prescription drugs, pharmacies will provide a duplicate empty bottle which is labeled and can be sent to camp.

Family physician

Date of last physical examination

I have filed out this form to the best of my ability and state that all of the above information is true. I authorize AEC to obtain any medical care necessary for my child in case of an emergency and to use any means of transportation available. Should hospital care be necessary, I consent to the administration of such anesthetics and the performance of such treatment, surgery or medication deemed necessary or advisable by the hospital/medical staff in the event that my child is at the hospital. I authorize the staff of AEC to take emergency measures as necessary in the event that none of the people listed on the Application for Enrollment can be reached. I release, indemnify, and agree to hold harmless, AEC, their directions, staff, and volunteers from any or all liability that may result from the participation of all activities. *

I agree

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