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


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


Birth Date:


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

o Both Parents



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 ...

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

1MB Sizes 0 Downloads 241 Views

Recommend Documents

Enrollment Form - English.pdf
Campsite hotel/motel single family dwelling other. Car shelter temporarily living with another family member or friend. Parent/Legal Guardian Signature.

supplier enrollment form - africa
All fields are required. Please contact ... Please send all invoices to c/o Iron ... F: Invoice should include a total of all goods and services and applicable VAT.

Emergency-Contact-Disc.pdf. Emergency-Contact-Disc.pdf. Open. Extract. Open with. Sign In. Main menu. Displaying Emergency-Contact-Disc.pdf. Page 1 of 1.

AUSD Enrollment Form V2_1.6.17 - ENGLISH.pdf
There was a problem previewing this document. Retrying... Download. Connect more apps... Try one of the apps below to open or edit this item.

2011-2012 Enrollment form w_ethnicity
To enroll: Mail to SYSA, P.O. Box 1113, Salem, OR 97308 or bring to rehearsal. 1. Player Profile complete with all information IF not previously submitted. 2. $25 nonrefundable enrollment fee for each member, check payable to SYSA. 3. Emergency Conta

2016-17 Enrollment Form -CH.pdf
Whoops! There was a problem loading more pages. Retrying... 2016-17 Enrollment Form -CH.pdf. 2016-17 Enrollment Form -CH.pdf. Open. Extract. Open with.

enrollment form for group insurance
Billing Division or Location: 1508319. A. Employee Information (Complete for ALL ... Date of Full-Time Employment: Rehire Date: B. Product Selection (Complete for ALL ... for coverage for my dependents at a later date, and if a physical examination o