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Student Medical History/Emergency Release


Child's Name: *   
Age: *   
Grade: *   
Parent/Guardian: *   
Child's date of birth: *   
Email: *  
Preferred phone: *    (please include area code)
Additional phone: *    (please include area code)
Other Emergency Name: *   
Phone: *   (please include area code)
Family Physician: *   
Phone: *    (please include area code)
Please include any medical or behavioral information that will help us provide a safe and respectful environment for your child:
Date of last tetanus shot: *   
List allergies:   
(e.g. nuts, bee sting, latex) If your child is taking medications, please be sure medications & instructions have been given prior to arrival at camp.
In the event an emergency arises where it is necessary for the student to be treated by other than the family physician, I hereby give my permission for him/her to be treated by a qualified physician or at a hospital. If necessary to the treatment, transportation by ambulance is also authorized. (Parent or Guardian is responsible for payment of medical treatment.) San Diego Natural History Museum and its staff and volunteers assume no responsibility for illness or injury which might occur during these classes. *   Parent or Guardian Must Sign Here (Please type full name or "I do not consent")
By initialing below, I hereby grant permission to the San Diego Natural History Museum, on my own behalf and on behalf of my spouse and/or child(ren), to use any photographs, videotapes, or any other likeness obtained in the course of this program, in any promotional, educational or other materials produced by or for the San Diego Natural History Museum, and I hereby waive any and all right to control, inspect, or approve such usage by the San Diego Natural History Museum: *   Please initial or type "I do not consent"
By initialing below, I understand that should the behavior of my child endanger the safety of others persons or themselves or cause unmanageable disruption to the class, I may be called to supervise my child and/or remove him/her from the class. *   Please initial or type "I do not consent"