SCAN AND EMAIL YOUR COMPLETED FORMS TO SALES@MODS.NET OR FAX TO 954.467.0456. Child’s Name _________________________________________ Grade ______ Age ______ Date of Birth ___/___/___ Street Address ________________________________________ City ________________State _____ Zip __________ MEDICAL INFORMATION (please write additional information on reverse side if more space is needed) Is your child taking any medications regularly? q No q Yes (If yes, please list below and state how often.) __________________________________________________________________________________________________ Does your child have any food or environmental allergies? q No q Yes (If yes, please list below.) __________________________________________________________________________________________________ Please list any other information that you feel will help us ensure your camper has the best experience possible. This includes: medical background, personality, disability, etc. ___________________________________________ __________________________________________________________________________________________________ I understand that Museum Staff will not hold or dispense any medication for my child. _________ (Initial) EMERGENCY CONTACT We will call or email these contacts in the order listed. List yourself if you are to be contacted. 1. Guardian’s Name ______________________________________ Relation to Camper ___________________________ Primary Phone _________________________________________ Alternate Phone ______________________________ Email Address (required) ____________________________________________________________________________ 2. Guardian’s Name ______________________________________ Relation to Camper ___________________________ Primary Phone _________________________________________ Alternate Phone ______________________________ Email Address (required) ____________________________________________________________________________ 3. Guardian’s Name ______________________________________ Relation to Camper ___________________________ Primary Phone _________________________________________ Alternate Phone ______________________________ Email Address (required) ____________________________________________________________________________ I authorize only the persons listed above to pick up my child from camp. NO EXCEPTIONS. _________ (Initial) Please note that in the case of sudden illness or misbehavior, an adult must be immediately available to pick up the child. Museum Staff may dismiss a camper at any time due to poor conduct. FIELD TRIPS • Some field trips may require a permission form. EMERGENCY TREATMENT RELEASE • In the event of a serious illness, accident, or injury that would require medical attention, 911 will be called and my child may be taken to the nearest emergency center. My signature below indicates permission for the Emergency Medical Staff to care for my child. HOLD HARMLESS • I agree to indemnify and hold harmless the Museum of Discovery and Science at 401 SW 2nd Street, Fort Lauderdale, FL 33312-1707, from any claims, damages, losses, costs and expenses resulting from the participation of my child in the Museum of Discovery and Science Camp. PROMOTIONAL PHOTOGRAPHY RELEASE • I understand the Museum of Discovery and Science may take photos/video of students/campers during the program for publicity purposes. q YES You may photograph my child. q I would like to receive photos through Brightwheel. q NO Do not photograph my child. My signature below indicates that I have read and understand the policies stated above and that I agree to abide by them. LEGAL GUARDIAN’S SIGNATURE ________________________________________________ DATE _______________ LEGAL GUARDIAN’S SIGNATURE ________________________________________________ DATE _______________ EMERGENCY INFORMATION THIS FORM MUST BE COMPLETED AND SUBMITTED FOR EACH CHILD ENROLLING IN CAMP.