SHELBURNE FARMS HEALTH FORM - Vacation Day 2012

1. Parent / Guardian Information

Welcome to our online health form! We hope this survey will simplify and streamline the registration process. On the first day of programming we will ask for your signature on a document created by your responses here. This first page collects parent / guardian information that will apply for each child you register. The remaining pages collect specific health information for your child(ren).

1. Parent / Guardian Information. Under email address, please confirm the address where you received your enrollment notification.

Parent / Guardian Information. Under email address, please confirm the address where you received your enrollment notification. Name(s)
Email address
Relationship to Child(ren)
Local Address
City
State
Zip Code
Phone 1 (best way to reach you)
Phone 2 (alternate)
Phone 3 (alternate)

2. If parent / guardian cannot be contacted in an emergency, please contact:

If parent / guardian cannot be contacted in an emergency, please contact: Name(s)
Relationship to child(ren)
Phone 1 (during program hours)
Phone 2 (alternate)

3. Health Insurance: to expedite care for your child(ren), we request but do not require the following information:

Health Insurance: to expedite care for your child(ren), we request but do not require the following information: Name of child(ren)'s physician
Physican phone
Insurance Provider
Name of Primary Account Holder
Account Number

4. Do you grant permission to publish in print, electronic, or video format, the likeness or image of your child(ren):

	Yes	No
for the general promotion of Shelburne Farms and its programs?	*Do you grant permission to publish in print, electronic, or video format, the likeness or image of your child(ren): for the general promotion of Shelburne Farms and its programs? Yes	for the general promotion of Shelburne Farms and its programs? No
for the use on a private site such as snapfish or shutterfly with viewing permission granted to families from your child(ren)'s program(s)?	for the use on a private site such as snapfish or shutterfly with viewing permission granted to families from your child(ren)'s program(s)? Yes	for the use on a private site such as snapfish or shutterfly with viewing permission granted to families from your child(ren)'s program(s)? No

5. Do you give permission to transport your child(ren) in camp vans and wagons?

Do you give permission to transport your child(ren) in camp vans and wagons? Yes

6. Will you be available on the first day of programming to sign a document created by your responses here?

Will you be available on the first day of programming to sign a document created by your responses here? Yes