WCDS | Medical Waiver & Emergency Form

A medical waiver & emergency contact form is required for each camper. Please provide copies of immunization records and a complete physical for each child NOT currently enrolled at Wakefield Country Day School.
Participant's Name*
First Last
Date of Birth*
Month
Day
Year
Parent/Guardian Name*
First Last
Cell Phone*
Work Phone
Address*
Street Address Address Line 2 City State ZIP Code
Emergency
In case of emergency, when parent/guardian can't be reached, please call:
Name*
First Last
Relationship*
Cell Phone*
Other Phone
Medical Information
Participant's Physician*
Phone*
Health Insurance Provider
Policy Number
Allergies (Please Specify)
Current Medication
Significant Past Injuries or Illnesses (Please Specify)
PARENTAL AUTHORIZATION CONSENT AND LIMITATION OF LIABILITY*
I agree to the privacy policy.
I GRANT PERMISSION FOR THE ABOVE-NAMED PERSON TO PARTICIPATE IN ALL ACTIVIEIS OF THE WCDS SUMMER ACADEMY 2022. I ASSUME ALL RISKS, HAZARDS, AND COSTS INCIDENTAL TO SUCH PARTICIPATION. I UNDERSTAND THE WCDS SUMMER ACADEMY, THEIR ADMINISTRATION, STAFF, EMPLOYEES AND BOARD MEMBERS WILL NOT BE HELD LIABLE FOR ANY INJURY, DAMAGE OR LOSS SUFFERED DURING CAMP. I AUTHORIZE WCDS TO EMPLOY MEDICAL ASSISTANCE FOR MY CHILD IN THE EVENT HE/SHE SUFFERS ILLNESS OR ACCIDENT WHILE ATTENDING WCDS SUMMER ACADEMY. I AGREE THAT WCDS SUMMER ACADEMY SHALL EXERCISE COMPLETE DISCRETION IN THE CHOICE OF PHYSICIAN OR OTHER MEDICAL PERSONNEL FOR MY CHILD. WCDS MAY ACT INDEPENDENTLY OF ME SHOULD IMMEDIATE ACTION BE DEEMED NECESSARY FOR THE SAFETY AND WELL-BEING OF MY CHILD.
Date*
MM slash DD slash YYYY

Emergency

Medical Information