Summer Camp Health Form - STL Rock School - St. Louis Area

Name: STL Rock School
Address: 1305 Baur Blvd, Olivette, MO, 63132, US
Telephone: 314-692-7625
Price range: 135-650

Parent First Name
Child First Name
Last Name
Email
Phone
Emergency Information
Please list name, phone number, and email to contact you in case of an emergency
Emergency contacts if parents cannot be reached
Please list name, phone number, and email to contact in case of an emergency
Pick Up Authorization
List of all people authorized to pick up your child. Please include a contact phone number as well
Allergies
Does your child have any allergies we should be aware of? (Seasonal, Dietary, or Medications)?
Social Challenges
Does your child have any social challenges we should be aware of? (Anxiety, ADD, ADHD, Spectrum Disorder)?
Medications We Should Be Aware Of
Does your child take any medication we should be aware of?
Outside Permission*
I grant my child permission to participate in supervised outdoor activities in the field adjacent to STL Rock School’s parking lot.
- Yes
Emergency Permission*
I hereby give permission for STL Rock School to use their judgment in arranging for my child’s emergency medical care in the event that I or my emergency contacts cannot be reached. I authorize STL Rock School to take necessary action for the welfare of my child. I further agree to pay all expenses involved and/or make insurance arrangements.
- Yes