Spring Break Camp Parent Questionnaire

Child's Name*

First Last

Gender*

Current Age*

Grade Level '22-'23 School Year*

School*

Home Address*

Street Address City State / Province / Region ZIP / Postal Code

Father's Name*

First Last

Father's Daytime Phone*

Mother's Name*

First Last

Mother's Daytime Phone*

Other Emergency Contact*

First Last

Other Emergency Contact Daytime Phone*

In case of emergency, notify first:*

In case of emergency, notify second:*

Name of Child's Physician*

Prefix First Last

Physician's Phone Number*

Special Instructions / Limitations / Allergies to foods, medications or other that we should know about?*

Medical Authorization*

Is camper taking any medication that must be given at camp?

Yes
No

If yes, please complete the following. Please administer to:

First Last

the following medication(s):

Dosage:

Time:

Vaccinations*

Is your child up-to-date on his/her vaccinations?

Yes
No

Is there anything that would be beneficial for us to know about your child that would help us to make his/her experience the best it can be? (ie: ADHD, autism, shyness, etc.) Please keep in mind that we do not have the staff available for one-to-one assistance.*

First Person Authorized to Pick Up My Child*

Besides parent names listed above, who else has permission to pick up your child?

First Last

Daytime Phone Number of First Authorized Person*

Second Person Authorized to Pick Up My Child*

Besides parent names and first authorized person listed above, who else has permission to pick up your child?

First Last

Daytime Phone Number of Second Authorized Person*

Photo Permission*

Does the Art Museum of South Texas have permission to photograph your child while participating in the Fine Art of Summer Camp activities? Photographs may be used on the AMST website, in the AMST newsletter or other Museum advertisements for promotion purposes.

Yes, I do give permission
No, I do not give permission

Outdoor Participation Permission*

Can you child participate in outdoor activities, weather permitting?

Yes, I do give permission
No, I do not give permission

Drinks/Snacks Permission*

Can your child partake in drinks and snacks which may occasionally be provided by camp personnel?

Yes, I do give permission
No, I do not give permission

Consent*

I will notify the Art Museum of South Texas if my child is exposed to any communicable diseases during the 3 weeks prior to camp. In case of medical emergency, I understand that every effort will be made to contact a parent/guardian of my child. In the event that I cannot be reached, I hereby give permission to the physician selected by the AMST to hospitalize, secure proper treatment for, and/or order injection, anesthesia or surgery for my child. I also understand that authorized personnel and/or volunteers of the Art Museum of South Texas will have the care and custody of my child named above during the camp hours of 9:00am - 3:30pm and/or during Pre/After Care hours) in the following camp sessions (press CTRL and click to select more than one session):

Select All
March 13-17, Spring Break Camp 2023

I agree to hold the Art Museum of South Texas and its authorized personnel and/or volunteers harmless against any and all liabilities arising from any activities described above.

Education

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Member

PROGRAMS &
EVENTS

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Your Visit

Spring Break Camp Parent Questionnaire

Education

Become A Member

PROGRAMS & EVENTS

Plan Your Visit

Become A
Member

PROGRAMS &
EVENTS

Plan
Your Visit