ENROLLED STUDENT Please enable JavaScript in your browser to complete this form.LayoutChild's Last Name *Student's Date of Birth *Physician's Name *Physicians Phone *Dentist's Name *Dentist's Phone *Preferred Hospital *Child's First Name *Student's Grade *PreschoolPre-KKindergartenGrade 1Grade 2Grade 3Grade 4Please choose your child's grade as of Fall 2024.Please check all that apply:AllergiesAsthmaDietary RestrictionsFears or PhobiasPhysical LimitationsSerious injury or surgery in the last yearOther Conditions or ConcernsPlease explain any checked boxes below.Explain Any Checked Items Above Please Check all that apply: InhalerEpiPenMedication (Prescribed or OTC)An Authorization to Dispense Medication Form must be completed for each item checked. NextLayoutName of Emergency Contact 1 *If Parent/Guardian is not available.Phone # of Emergency Contact 1 *If Parent/Guardian is not available.Place of Employment Parent /Guardian *Work Phone #Name of Emergency Contact 2 *If parent/guardian is not available.Phone # of Emergency Contact 2 *If Parent/Guardian is not available.Place of Employment Parent/ Guardian *Work Phone # NextAuthorizations and Permissions Names of others authorized to pick-up your child *Names of others NOT authorized to pick-up your child *LayoutProvide emergency medical treatment/transportation *AuthorizeDo Not AuthorizeParticipation in and transportation to on/off campus activities and events *AuthorizeDo Not AuthorizeWatch G/PG rated movies *AuthorizeDo Not AuthorizeUse or distribution of images or personal information on any publications, social media, or promotional materials *AuthorizeDo Not AuthorizeApply sunscreen *AuthorizeDo Not AuthorizeParticipate in activities including but not limited to swimming *AuthorizeDo Not AuthorizeWaiver of Liability *Waiver of Liability I hereby permit my minor child to participate in Cape Care administered by Cape Elizabeth Community Services located at the Community Center during the 2024-25 school year. In consideration of my minor child being allowed to participate in Cape Care, I, for myself and my minor child, hereby agree to release, discharge, indemnify and hold the Town of Cape Elizabeth, Community Services, and their agents and employees harmless from any liability claims, demands, costs or damages arising out of program activities, and transportation, by negligence or otherwise, which I or my minor child might have. I, the undersigned, further authorize anyone working for Community Services to call for such medical care for my child or to transport my child to the appropriate medical clinic or hospital, if in the opinion of anyone working at Community Services, medical attention is needed for my child. The undersigned agrees that upon transporting the child to any medical facility, clinic, or hospital, the responsibility of Community Services shall be fulfilled and Community Services shall not have any further responsibility for the child. We further authorize the attending physician to administer any necessary medical attention in the event we cannot be reached at the provided telephone numbers. I understand that participation may include transportation by buses/vans owned and operated by the Cape Elizabeth School Department. The release is binding, and I so understand, not only upon my heirs, administrators, executors, and assigns, and I herewith again reaffirm my free and willing intent to execute it, acknowledging a complete understanding of terms and conditions and the totality of its effect, and the totality of the waiver of rights that I would otherwise have had, had this agreement not been executed. I certify that the above-named minor child is in excellent health and that there are no limits to my child’s participation except as stated in writing. I further certify that the Town of Cape Elizabeth / Community Services has on file all current immunization records. LayoutSignature *Date *Submit
