Student Information Form

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Student / Camper First Name

Student / Camper Last Name

Date of birth

Gender

Age

Health Insurance Number

Expiration Date

PARENT NAME

House number

City

Telephone number

Street Name

Postal code

Telephone number (2)

LEAVING AUTHORISATION: I hereby authorize my child to leave the theatre alone at the end of the day/class

Yes

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

EMERGENCY CONTACT 2

Phone

MEDICAL INFORMATION: Does your child have any of the following medical conditions: diabetes, asthma, hyperventilaton, panic, epilepsy, allergies?

Yes

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

Please specify medication and dosage

MEDICAL INFORMATION: Are there any exercises or activities that your child cannot participate in?

Yes

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 work and our staffing.

Yes

If yes, please specify

FULL NAME

I have read and accept the media consent form

I accept terms & conditions

DATE

SIGNATURE

Info received