Fun with Fiddle & Art                   Emergency Information

Child's Name_________________________________________________________________________________

Physican________________________________________ Phone_______________________________________

Insurance & Policy No.________________________________________________________________________

Please describe any allergies or dietary restrictions the child has:


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Emergency contacts:

Mother __________________________ Daytime/Cell Phone_________________________________________

Father___________________________ Daytime/Cell Phone__________________________________________

Other contact______________________ Daytime/ Cell Phone________________________________________



In the event of a serious illness or injury, I authorize Fun With Fiddle & Art employees to seek emergency medical care for my child. I hold Fun With Fiddle & Art employees harmless from all liability resulting from accidents or illness. I verify that all information on this form is complete and accurate. I have read and understand all information contained herein.


Parent Signature______________________________________________________________________________

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Photography Release

____ YES, I consent to having Fun with Fiddle and Art, or parents/friends of participants, photograph or videotape my child. I also agree that Julie Mellon & Eileen Scholl may use the photos and videotapes to promote Fun with Fiddle and Art camp.  I further understand that Julie & Eileen agree not to use or reveal my child's name.


____ I DO NOT CONSENT to having Fun with Fiddle and Art, or parents/friends of participants, photograph or videotape my child.


Child's Name__________________________________________________________________________________________________

Signature of Parent/Guardian__________________________________________________________________________________

Date__________________________________________________________________________________________________________