Authorization To Consent To Treatment Of A Minor

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Medical /Liability Release Form
(I), (We), the undersigned, the parent(s)/guardian(s) of ________________________, a minor, do hereby authorize Science Explorers, Inc. and
contractors, for the undersigned to consent to any emergency treatment deemed advisable by, and rendered under the general or specific
supervision of any physician/surgeon licensed under the provisions of the Medical Practices Act on the medical staff of a licensed hospital, whether
such diagnosis or treatment is rendered at the office of said physician or said hospital. It is understood that this authorization is given in advance of
any specific diagnosis, treatment or hospital care being required but is given to provide authority and power on the part of our aforesaid agent(s) to
give specific consent to any and all such diagnosis, treatment or hospital care which the aforementioned physician, in the exercise of his/her best
judgment, may deem advisable.
We have registered our child for this program and have given permission for said child to attend and participate in the Science Explorers Camp.
Date: _____________________
Name of Child: _________________________________________________________________
Health Insurance Provider: __________________________________ Health Insurance Policy Number: ______________________
My child has the following conditions or allergies that may occur: _______________________________________________________
Parent(s) or Legal Guardian(s): ______________________________________________________________________ Please print
Parent(s) or Legal Guardian(s): _______________________________________________________________________Signature(s)
I, the undersigned, agree to save and hold harmless Science Explorers, Inc. and respective departments, organizations, boards, commissions,
officers, agents, and employees and contractors from any liability whatsoever for any harm, personal injury, or property damage which I or my child
______________________________________________ may cause or suffer arising out of his/her participation in the Science Explorers Program.
Parent(s) or Legal Guardian(s): _______________________________________________________________________ Please Print
Parent(s) or Legal Guardian(s): _______________________________________________________________________ Signature(s)
If your child needs medication to be administered during the camp day, please review and sign the following:
Check one:
My child does not need medication during the camp day.
My child does need medication during the camp day.
The medication, in its original container must be labeled with a prescription by a pharmacist or a physician. DO NOT send unlabeled containers to
camp. Any medication that comes under the law of controlled substances (such as Ritalin) must be presented to the camp instructor by the
parent/guardian. All medications will be kept in the instructor’s possession. Campers who need to self-administer medications (such as inhalers) are
permitted to do so with the instructor’s permission and are required to report each self-administered dose to the instructor.
I hereby grant permission for the instructor to oversee the intake of medication to my child as listed below:
Parent(s) or Legal Guardian(s): _______________________________________________________________________ Please Print
Parent(s) or Legal Guardian(s): _______________________________________________________________________ Signature(s)
Name of Child __________________________ Grade __________
Name of Medication _______________________________
Time to be given ____________ Amount to be given ___________ Possible Side Effects _________________________________
Additional Instructions _________________________________________________________________________________________
Camp Location______________________________________________________________________ Date ____________________


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Parent category: Legal