Curiosity Camp Health and Liability Form

Thank you for signing up for Curiosity Camps

Child's Name

Child's Age

Child's Date of Birth

Child's Current Grade

Parent/Legal Guardian #1 Name

Parent/Legal Guardian #1 Cell

Parent/Legal Guardian #1 Email

Parent/Legal Guardian #2 Name

Parent/Legal Guardian #2 Cell

Parent #2 Email

Street Address

City, State, ZIP

Emergency Contact Name (other than Parent/Guardian)

Relation to Child

Cell Phone

Name of additional persons authorized for pick-up (state issued i.d’s are required to check out campers)

Relation to Child

Cell Phone

Is there anyone UNAUTHORIZED to pick up your child or a custodial situation we should be made aware of?

Medical Release Information - Primary Physician

Clinic Phone Number

Please let us know of any medical conditions or special needs your child may have:

Is there anything else you would like to share about your child?

Medication Policy

I understand that CMSM Staff does not administer medication. If my child has severe allergies of other conditions that require special monitoring we welcome working with the CMSM staff to see if we can accommodate those needs in our public setting.

Behavior Policy

I understand that CMSM Staff has the right to remove children who are disruptive to the program after redirection. Please refer to the Behavior Policies stated in the policies and procedures information.

Waiver

I/We the parents of the named camper, do hereby grant permission for them to participate in activities presented in CMSM Camps, AND understand that the Children’s Museum of Southern Minnesota employees, officers, and volunteers are not responsible for any liability arising out of participation in this Camp

I understand that I will be notified in the case of a medical emergency involving my child followed by my listed Emergency Contact. In the event the above cannot be reached I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured or becomes ill.

I understand that a State Issued I.D. that matches the name of persons authorized to pick up your child is required to release your child at the end of the program.

Please Select One - Photo Permission Policy

I grant to The Children’s Museum of Southern Minnesota, its representative and employees the right to take photographs and audio/or video recordings of my child in connection with this Camp. I agree that CMSM may use such photographs of my child in promotional videos, websites, Enews, and printed material. I do NOT grant to The Children’s Museum of Southern Minnesota, its representative and employees the right to take photographs and audio/or video recordings of my child in connection with this Camp. I agree that CMSM may not use such photographs of my child in promotional videos, websites, Enews, and printed material.

By placing your email below, you are giving permission for CMSM staff to send updated camp information, as well as upcoming CMSM programs in the future.

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Curiosity Camp Health and Liability Form

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