Park District of Oak Park - Early Childhood Participant Emergency Form 2024-2025

Parent/ guardian

Already have an account?

Connect

You will receive a confirmation by email.

First name *

Last name *

Email *

Mobile *

Other phone (home or work)

Child

First name *

Last name *

Gender *

Date of birth *

Grade

Address

City

Country

State/Province

Zip/Postal code

Parent / Guardian #2

First name *

Last name *

Email *

Mobile *

Other phone

Authorized Contact

Relationship

First name *

Last name *

Email *

Mobile *

Other phone

Can pickup child

Birth Certificate

If you are new to our Preschool program and have not given us the birth certificate. It is required.

Health Care Provider

First name *

Last name *

Email *

Mobile *

Address

City

Country

State/Province

Zip/Postal code

Hosptial *

Allergies *

Allergy

Reaction

Anaphylaxis Risk?

Bringing Epi-pen?

Yes No

+ Add

Medications *

Medication

Strengh

Dose Qty

Dose Form

Time of the day

+ Add

Please bring this filled form on the first day if the participant will require medication to be administered while at the program.
Permission to dispense medication

Diet and Activity *

Diet Restrictions?

Activity Restrictions?

+ Add

Background & Other Activities

Does the participant have any siblings? If so, please provide name and age.

Do any other people live at your residence?

Religious Affiliation (optional - for arts and crafts planning and holiday celebration)

Primary Language Spoken at Home

Does the participant have any tendencies or habits (i.e. uses an object to self-sooth, sucks thumb, bites nails, etc.)?

Does the participant have any fears (i.e. thunderstorms, animals, etc.)?

Have any major family events or transitions occurred over the past year? i.e. new baby, move, divorce, etc.?

Is currently enrolled in other programs and/or receiving services (i.e. speech, occupational therapy, afternoon daycare, other preschool programs, etc.)?

Would you like your family information included in the class list directory available to program participant families?

Is there any additional information about the participant that you would like to share with us?

Ages and Stages Questionnaire

I have completed the Ages and Stages Questionnaire

Yes No

Certificate of Child Health Examination

Please complete the document via the link below and upload.

https://dph.illinois.gov/content/dam/soi/en/web/idph/files/forms/certificate-ofchild-health-examination-03032017.pdf

Participant Code of Conduct
We want our camps to be a great experience for everyone involved. In order for this to happen, everyone needs to play a role in
creating a positive and safe environment. The Park District and Camp Staff appreciate your cooperation and understanding of
these rules:
- Showing respect to all participants, staff, equipment and facilities
- Behaving in a way that results in only appropriate, kind, and positive interactions with others
- Leaving any unnecessary items at home that may cause a distraction at the program, including toys, cell phones, electronics, or
items that appear to look like weapons
- Refrain from causing bodily harm to self, other campers, or staff
- Take direction from staff
- Refrain from chewing gum
Consequences for not following the rules listed or any other rules developed for the specific camp locations will be shared with the
participants. In order for this to be successful, the Park District asks for parents’ support in enforcing these guidelines. Staff will
address each incident with the participant (and parent if the situation requires) in a positive and fair manner meant to help teach
participants how to make better choices. In instances where re-direction and a reminder of the rules is not effective, staff will follow
the following discipline procedures:
- 1st infraction: Verbal Warning
- 2nd infraction: Time-Out/loss of privilege, parent notification
- 3rd infraction: Behavior Management Report filled out (signed by parent & camper)*
- 4th infraction: Suspension or dismissal from all Park District Camps
Behavior management reports may be completed for the following:
- Fighting, teasing, or using inappropriate language toward other campers
- Damaging property or equipment
- Damaging property of other campers
- Disrespecting or disobeying Camp or Park District Staff
- Leaving designated group or grounds without permission
- Stealing
- Gang Association (participant will be dismissed from the program)
The Program Supervisor, Camp Coordinator, and Site Supervisor will interpret these rules. A child may advance through the levels
of the Discipline Procedures, or may jump to a higher level dependent upon the severity of the behavior. The Park District reserves
the right to dismiss a participant whose behavior endangers the well-being of themselves or the program and no refunds are issued
in these circumstances.
Waiver
I give permission for my child to participate in this program, field trips or activity and hereby waive, release and forever discharge
any and all claims against the Park District of Oak Park. I have read the Participant Code of Conduct as well as the Parent
Handbook (link below) and have explained the information to my child. I have specifically reviewed policies regarding late fees,
late pick-up, and the program discipline procedures. In the event that a guardian or a designated responsible adult cannot be
reached, I authorize the Park District of Oak Park to send my child (properly accompanied) to the nearest hospital for emergency
medical treatment, and authorize any medical treatment which may be advised or recommended by the physicians of the hospital.
Please indicate that you have read and agree with the above statement and acknowledge that you have received the Parent
Handbook by signing below.

I read and accept *

Please read and scroll to the bottom to accept.

Electronic signature*

Please sign your name inside the box