Manchester Craftsmen's Guild: Summer Studios Enrollment Form

Manchester Craftsmen’s Guild: Summer Studios Enrollment FormSummer 2011 © 2011 Manchester Craftsmen’s Guild, a subsidiary of Manchester Bidwell Corporation Page 4 / 66Emergency Contact InformationPlease indicate the person not listed under Parent/ Guardian that MCG should notify in the event of an emergency:Last Name: First Name: Relationship to Student:Home Phone:Alternate Phone:Physician Contact My child does not currently have a physician he/she regularly visitsPhysician Name:Phone:Alternate Phone:Student Medical HistoryIt is extremely important that you provide details about any medical history and existing conditions that may affect your child ifhe/she requires treatment due to a medical emergency.Date of late tetanus vaccination:My child experiences(check all that apply): Asthma Epilepsy Bleeding Disorder Migraines Allergies (please list): Diabetes Kidney DiseaseOther physical or behavioral conditions that a medical professional handling your child should be aware of(please describe):Please list any medications your child is currently taking: NoneIs your child currently under the care of a physician for an ongoing condition? No Yes (please explain):Parental/ Guardian ConsentI understand that Manchester Craftsmen’s Guild does not have medical professionals on staff, and that MCG teachers orother staff will not administer or provide any medication to my child. I accept that in the event of an incident with my child,MCG will make every effort to get in touch with the emergency contacts in the order they are listed above. If none of thesecontacts can be reached and/or immediate emergency action must be taken, I hereby authorize MCG to secure all proper andrequired treatment deemed necessary under the then-existing circumstances to stabilize my child until such time as I can bereached to personally grant consent. I understand that the information provided on this form will only be used asneeded in the event of an emergency, that it is my responsibility to notify MCG of any changes to the informationprovided, and that my failure to return a signed copy assumes consent.Parent/ Guardian SignatureDate