Health Form WCFA Health & Emergency Contact Form Camper families must complete this form prior to the first day of camp. Student/Camper InformationStudent/Camper's Name(Required) First Last AgeAt time of first day of camp/classPronounsex: she/her. they/them, he/him, etc. Student's Gender Identity Female Male Transgender Non-binary/non-conforming Prefer not to respond Student's ethnicity Caucasian / White Black or African-American Latino or Hispanic Asian Native American Native Hawaiian or Pacific Islander Multi-racial Prefer not to say We ask for this optional demographic information in order to provide data for our funding/grant applications. What is your annual average household income? Less than $20,000 Between $20,000-$50,000 Between $50,000-$80,000 Between $80,000-$100,000 More than $100,000 Additional Participant Information: Have any dietary restrictions? Used an individualized education plan (IEP) during the previous school year Ever have need for an aide at school? None of the above Medications No, this child will not be taking any medication during the program Yes, this child will bring self-administered medication to the program I need to speak with someone about administering medication at the program If the child has any known allergies, please let us know what they are here:Please elaborate on any of the above if necessary:Please also use this space to explain any other physical, mental, emotional or social health situations that staff should be aware of to ensure this child has the best possible experience at camp/class.Home Address(Required)ex: 5 Maple Lane, Warwick, RI 02886Parent or Guardian's Email(Required) Enter Email Confirm Email Emergency Contact #1 Name(Required)Phone(Required)Emergency Contact #2 NamePhoneEmergency Contact #3 Name(optional)PhonePick Up Authorization All emergency contacts listed above are authorized to pick up the child named on this form I would like to list different/additional people authorized to pick up Other Authorized Pick-Up:What school did this child most recently attend?ex: Cedar Hill Elementary, WarwickHow did you hear about this camp/class?Social MediaGoogleWord of MouthRefer a FriendPast ParticipantEmail from WCFAOtherMedia Release Consent By checking this box I give WCFA permission to include your child's image for marketing purposes.WCFA frequently takes photos of our classes and camps in action to use for future marketing purposes and in grant applications. We do not include the child's name. Would you like to sign up for our monthly email newsletter? Yes No
