GSK Science in the SummerTM Consent and Disclosure form

CHILD AND PARENT INFORMATION

Participant’s Name:*
Birth Date:*
 / 
 / 
Parent/Guardian Name:*
Address:*
Day Phone:*
-
Alternate Phone:*
-
Child’s Sex:*
Person to notify in case of emergency, other than above: *
Primary Phone*
-
Alternate number:
-

How would you describe your child?

Gender
Race (Select all that apply)
Ethnicity

CHILD RELEASE INFORMATION

Exploration Place has permission to release my child to the parent/adult contacts listed above and the following adults (18 and over) with photo ID:

Name:*
Relationship to child:*
Full Name:*
Relationship to child*

QUESTIONS TO HELP US BETTER SERVE YOUR CHILD

Does participant have any significant illnesses or disabilities that would in any way prevent or limit full participation in camp activities?*
If yes, please explain:
Does participant have any allergies?*
If yes, please list
Is there any other information that will allow us to better serve your child?

HOLD HARMLESS AND RELEASE

  1. By signing this document, I hereby authorize the use of the information on this form for medical treatment of the participant, and I authorize the release of this information to the named insurance company as needed, in presenting any claim for benefits. I have the right to revoke this consent at any time except where Exploration Place, Inc. (EPI) has already used or disclosed such health information in reliance on this Consent form.

  1. I am aware of all the inherent damages and risks involved in this EPI program including: bodily injury, sprains, fractures, dislocations, lacerations, concussions, skin disease, eye, head, neck or back injuries, or death. I give the participant the permission to participate in all activities of this program.

  1. I understand that EPI does not provide any accident or medical insurance and that I agree to be financially responsible for all medical expenses whatsoever.

  1. I agree, on behalf of myself, the participant, my assigns, executors and heirs, to release, indemnify and hold harmless EPI and its directors, officers, agents and employees from any and all liability, damage, or claim of any nature arising out of or in any way related to the participant’s participation in this program, except claims or losses caused by the sole gross negligence of EPI.

  1. I understand this agreement to be a release of all claims and causes of action for participant’s injury or death or damage to participant’s property that occurs while participating in the described activity and it obligates me to indemnify the parties named for any liability for injury or death of any person and damage to property caused by the participant’s negligent or intentional act or omission.
Parent/Guardian Signature:*