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STUDENT INFORMATION FORM
Student / Camper First Name
Student / Camper Last Name
Date of birth
Gender
Email
Age
Health Insurance Number
Expiration Date
PARENT NAME
House number
City
Telephone number
Email
Street Name
Postal code
Telephone number (2)
Email
LEAVING AUTHORISATION: I hereby authorize my child to leave the theatre alone at the end of the day/class
Yes
No
Person 1 authorised to leave with your child
Person 2 authorised to leave with your child
Person 3 authorised to leave with your child
EMERGENCY CONTACT 1
Phone
Email
EMERGENCY CONTACT 2
Phone
Email
MEDICAL INFORMATION: Does your child have any of the following medical conditions: diabetes, asthma, hyperventilaton, panic, epilepsy, allergies?
Yes
No
If yes, please specify
MEDICAL INFORMATION: Does your child need medication on a regular basis or carry with them medical devices (e.g. and Epipen)?
Yes
No
Please specify medication and dosage
MEDICAL INFORMATION: Are there any exercises or activities that your child cannot participate in?
Yes
No
If yes, please specify
MEDICAL INFORMATION: Do you authorise The Montreal Children's Theatre to adminsiter the following over the counter medication to your child if necessary?
Acetaminophen
Lozenges for a cough/dry throat
Eye drops
Antihistamines
Comments
MEDICAL INFORMATION: Does your child have any social, emotional or learning needs that The Montreal Children's Theatre should know about? Any informaton is helpful in allowing us to plan our activities, our group wprk and our staffing.
Yes
No
If yes, please specify
FULL NAME
I have read and accept the media consent form
I accept terms & conditions
DATE
SIGNATURE
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Info received
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