Ms. Madde’s Art Camp 2004 

Please complete this form. Application will not be processed without complete information. Please print.

Camper 1 _______________________ Date of birth _____________

Camper 2 _______________________ Date of birth _____________

Mother’s name ____________________________________________

Phone number ______________________

Address __________________________________________________

Employer ___________________________ Work # _______________

Father’s name _____________________________________________

Phone number ______________________

Address __________________________________________________

Employer ___________________________ Work # _______________

The following persons are allowed to pick up my child and/or may be called in case of an emergency if I am unable to be contacted:

Name ______________________________ Phone # ________________

Name ______________________________ Phone # ________________

Name ______________________________ Phone # ________________

Need Aftercare? ____________________________

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Health information form

Ms. Madde’s Art Camp 2004

1125 Spa and Hilltop

Annapolis, Maryland 21403

Camper’s Name _________________________________________

Medical Information

Family Physician ________________________ Phone # ___________

Insurance carrier _______________________ Policy # _____________

Known Allergies ____________________________________________

___________________________________________________________

Is there any special health information that we should know about your child? ____________________________________________________

___________________________________________________________

___________________________________________________________

In case of an emergency, I understand that every effort will be made to contact the parent/guardian of my child. In the event that I can not be reached, I hereby authorize emergency medical care for my child during attendance at Ms. Madde’s (Kneseth Israel’s Camp) Art Camp. I understand that I am financially responsible for any expense for medical care of transportation incurred on my child’s behalf. I hereby release the art camp and its employees from any responsibility for injuries during my child’s participation in Ms. Madde’s camp program.

Parent(s) printed name(s) _______________________________________

Signature(s) __________________________________________________

Date _____________________ email address _______________________