440 N. Broad St., B1 Philadelphia, PA 19130 Phone: (215) 400- 5589

www.philasd.org/pstv

PSTV  Enrollment,  Emergency  Contact  and  Health  Form Please Print Student's Name:

___________________________________________

Birth Date:

________________

Address: ___________________________________________________________________________ City: ___________________________________ Contact Phone: _____________________________ Child Lives with:

o Both Parents

State:

_______________

Zip: ________________

E-mail: ________________________________________

o Mother

o Father

o Other:____________________

Guardian 1:_____________________________________ Contact #: ___________________________ Guardian 2:_____________________________________ Contact #: ___________________________ Emergency Contact(s): Emergency contacts are in addition to gaurdians listed above.

Must be 16 yrs old or older and authorized to pick-up.

Contact 1:______________________________________ Contact #: ___________________________ Guardian 2:_____________________________________ Contact #: ___________________________ Allergies: Please be specific {i.e. contact, airborne, ingested} and describe reaction {swelling, rash, death} - Allergies to foods, drinks, insect bites, medications, other: o Food {please specify}: __________________________________________________________ o Medication {please specify}: __________________________________________________________ o Other {please specify}: __________________________________________________________ Has your child ever been stung by a bee?

o Yes

o No

Medical Conditions / Medications: Please list any medical conditions we should be aware of or any current medications _______________________________________________________________________________________ _______________________________________________________________________________________ __ Physician’s Name:_________________________________ Medical/ Hospital Insurance: ________________________________________ Group: _______________

Type: ______________________

Phone: _________________________

Non-prescription medications: Which of the following over-the-counter medications is PSTV authorized to use as needed?

o Other {please specify}: __________________________________________________________ Medical & Liability In the event that none of the above emergency contacts are able to be reached, I authorize PSTV to seek medical attention, if needed, from a medical care provider. I also release PSTV , all its employees, staff, directors, and affiliated personnel from any liability, cost, loss, damage or expense of any kind arising out of any injury or death occurring on PSTV property, or during any activities, or while traveling to and from PSTV on behalf of myself, my children, or any family member, including time-frames before and after camp activities. I further acknowledge that PSTV is not responsible for my child in any way. Student Signature _________________________________ Date: __________________ (If udner 18) Parent Name _________________Parent Signature _________________________ Date: _____________________

PSTV Enrollment, Health & Emergency Contact form 20160303.pdf ...

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