CONSENT AND DISCLOSURE FORM HOMESCHOOL

CHILD AND PARENT INFORMATION

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

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*

MEDICAL HISTORY

Has participant had any other significant illnesses, injuries, or currently taking any medication that would in any prevent or limit full participation in camp activities? *
If yes, please explain:*
Please list the date of the last immunization for each of the following: Tetanus, MMR, & Chicken pox *
Does participant have any allergies? *
If yes, please list:*
My child may be given the following over-the-counter medications if my child needs them, without contacting me: *

QUESTIONS TO HELP US BETTER SERVE YOUR CHILD

Have there been any changes in the family recently such as divorce, death, etc.? *
Does your child have any particular fears such as dogs, sirens, storms? *
How do you reassure or reward your child? *
Is there any other information that will allow us to better serve your child? *
Has your child had any unexplained symptoms of infectious disease or been exposed to known infected persons in the last 2 weeks? *

HOLD HARMLESS AND RELEASE

1. I am aware of all the inherent damages and risks involved in this Exploration Place, Inc. 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.

2. I understand that Exploration Place, Inc. does not provide any accident or medical insurance and that I agree to be financially responsible for all medical expenses whatsoever.

3. I agree, on behalf of myself, the participant, my assigns, executors and heirs, to release, indemnify and hold harmless Exploration Place, Inc. 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 Exploration Place, Inc.

4. 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:*
Does participant have Health Insurance?*
Name of Insured*
Name of Insurance provider*
Group Number*
Relationship to Participant: *
Preferred Hospital(s) in case of emergency*
I hereby give my consent for treatment of (child's full name & date of birth)*

This authorization covers any procedure, which may be deemed advisable by the attending staff physician, including emergency medical attention and treatment.  The undersigned verify that the above health insurance billing information is true and correct to the best of his/her knowledge.

Signature of person authorized to give consent *
Date Form Signed*
Address (if different than Participant’s)