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: ___________________________________________________