Camper Records, Permissions and Releases

Camper's Name *
Camper's Name
Camper's Date of Birth *
Camper's Date of Birth
PARENT/GUARDIAN INFORMATION
Primary Parent/Guardian Contact *
Primary Parent/Guardian Contact
Primary Parent/Guardian Phone Number *
Primary Parent/Guardian Phone Number
EMERGENCY CONTACT INFORMATION
Emergency Contact #1 *
Emergency Contact #1
In addition to the named parent/guardian(s) above
Emergency Contact #1 Phone Number *
Emergency Contact #1 Phone Number
Emergency Contact #2 *
Emergency Contact #2
In addition to the named parent/guardian(s) above
Emergency Contact #2 Phone Number *
Emergency Contact #2 Phone Number
HEALTH AND DEVELOPMENT INFORMATION
Please list any dietary restrictions your child may have:
Please list any allergies your child may have:
Please list any health issues your child may have (frequent headaches, sinus infections, earaches, etc.):
Please list any psychological diagnoses you feel our staff should know (for both safety and to best meet your child’s needs):
Please list any developmental issues or needs you feel our staff should know (for both safety and to best meet your child’s needs):
Please list any phobias or heightened sensitivities your child may experience:
Please list any other health or development items you feel our staff should know:
HEALTH CONDITION FORMS
If the answer is 'yes' to any of the following questions, please contact admin@heartwoodalc.org as soon as possible to discuss proper medical and/or legal protocol.
Does your child take prescription medication, have a debilitating or life-threatening condition, have asthma, diabetes or a seizure disorder? *
PERMISSIONS - Water Play
PERMISSIONS - Image Use
I give permission for my child to be included in any image recording connected with the school’s program, specifically external-facing media. This might include postings to the external-facing Facebook account, external-facing Instagram account or ALC blogs that are intended to be shared with the ALC community worldwide. I understand that those images may be used as documentation on the school’s website, newsletter or marketing materials.
If in the event of an emergency, Heartwood ALC is unable to contact the above listed legal guardians, I hereby authorize an adult(s) from Heartwood ALC, in whose care said minor child has temporarily been placed, to authorize and consent to any medical treatment, procedure, or provision of medication of any kind for said minor child, solely in discretion and judgment of such above named adults, and to stand in my place in all respects concerning the care and provision of medical treatment to the minor child. I hereby authorize any provider of medical services to rely on this consent form. I waive any claim against such provider with respect to any provision of medical treatment, including provision of medication, to such minor child, as instructed by the name adults to whom this power is granted, which claim would be based on an absence of parental consent for provision of medical treatment of minor child.
I give permission for my child to participate in field trips that will require leaving the school grounds during and/or after school hours. I understand that under present Georgia law, if my child is riding in a private passenger automobile which is involved in an accident, he/she may be primarily covered for bodily injury under my family automobile policy, and I agree to submit any medical bills incurred to my insurance company for payment and release Heartwood Agile Learning Center, including its agents and employees, from liability. If my child is being transported by commercial carrier or other leased or rented vehicles and an injury occurs, I understand that I shall look to the commercial carrier or owner of the other leased or rented vehicle to pay any medical bills incurred as a result of such injury and shall release Heartwood Agile Learning Center, including its agents and employees, from liability. If my child is injured while participating in the field trip, I agree and understand that liability arising out of said field trip is assumed hereby and shall be at the sole and exclusive risk of the undersigned.
I have been advised and understand that Heartwood Agile Learning Center is exempt from licensing through Georgia Department of Early Care and Learning’s Bright From the Start program. In addition I have been notified that Heartwood Agile Learning Center carries liability insurance.