Professor Gizmo’s Science Camp Parental Consent Form
Birthdate _______________ Age ______ Grade _______ Male or Female ____
Student’s Address__________________________________________________
_________________________________________________
Parent or legal guardian’s name _______________________________________
Contact phone number(s) during camp hours _____________________________
Other Person(s) authorized to pick up my child __________________________
Please list in the space below ANY allergies, medical conditions, or medications that we need to know of
:
___________________________________________________________________________________
___________________________________________________________________________________
Photo Release: I give Dennis and Dana Humphrey permission to photograph or videotape my child during science camp activities and to use the photographs/videotape in any promotional materials for publicity and marketing purposes of science camp.
_________________________________________ _____________
______________________________________ _____________
Insurance coverage by:
_______________________________________
Policy holder:
___________________
Policy #:________________________
Waiver and Consent for Emergency Treatment:
I hereby give my permission for my child to attend and participate in all activities at this camp. In consideration of the right to participate in these activities, I waive and release any and all rights and claims for damage I may have against Dennis or Dana Humphrey for any and all injuries suffered by my child while participating in these activities. I give my consent to emergency treatment as may be needed for the welfare of my child.
Parent/Guardian’s Signature Date
Parent/Guardian’s Signature Date