Days Off Club Emergency Form

Parent/Guardian Information

Medical Information

Please provide information below that will help us to create a safe and healthy environment for your child. Lack of detailed information compromises our staff’s ability to successfully accommodate your child. The Carol Stream Park District is not responsible for any injuries, complications, damages or losses due to lack of provided information. Many resources and adaptations are available to assist your child in having a successful summer. If your child has medication that may need to be administered by CSPD staff or medication that may need to be self-administered (including asthma inhalers), please complete the Permission to Dispense Medication Form.

If unable to contact a parent/guardian and if necessary, we will call emergency services (911) and your child will be transported to the nearest hospital at the parent/guardian’s expense. Please see the parent handbook for additional medical procedure information.
If your child will self-administer or need staff to administer medication (including asthma inhalers, epi-pens, or any other medications) while at camp, a Permission to Dispense Medication Form must be completed.
Please note that a minimum of two weeks is required in order to secure a one-on-one assistant.

Authorized Contact and Release Information

Parents/Guardians listed earlier with custody already have pick-up authorization. Please list siblings, parents without custody, relatives or friends who are also authorized to pick-up your child. All individuals must present a picture I.D. in order for your child to be released into their custody. Only the custodial parent may approve changes or additions to this list. For emergency purposes, at least one authorized person must live within five miles of Carol Stream.

First Authorized Individual

Second Authorized Individual

Third Authorized Individual

Fourth Authorized Individual

Fifth Authorized Individual

Additional Information

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