(Printable Medical/Liability Form)
Child's Name: ________________________________________________
Street Address:_______________________________________________
City:_____________________________ Zip:________________
Allergies: ______________________ Other Medical Conditions: _________________________
Are all immunizations records current?_______________ Date of last tetanus shot:__________
Physician: __________________________Phone: _____________________________
Medical Insurance Company: ______________________________________________
Policy Holder's Name: __________________________Policy #___________________________
Emergency Information
Mothers Name _______________________________ Home phone: ________________________
Work Phone: __________________________________Cell / Pager:________________________
Fathers Name: ________________________________Home Phone: _______________________
Work Phone: __________________________________Cell /Pager:_________________________
In an emergency when parent /guardian cannot be reached, please contact the following:
Name: _________________________________________Home Phone:_________________
Work phone: ___________________________________Cell/Pager:____________________
Name:___________________________________________Home Phone:________________
Work phone: ____________________________________Cell/Pager:__________________
We the parent/guardian authorize Destination Science to arrange emergency medical care for the above named child while at the Destination Science Camp. We also hereby release Destination Science and Stetson University its agents, owners and employees from any claims for accident, injury or loss of valuables that may occur during his /her stay at the camp. My signature below acknowledges my release and waiver of any claim for damages from any such accident, injury or loss. I hereby give permission to photograph the above named child and allow use of pictures in advertising or reports about Destination Science Camp.
Parent / Guardian Signature: _________________________ Date: ____________________
Parent / Guardian Print Name: ___________________________________________________