Medical Release Information |
| 1. Does the student have any allergies (food, medication, animals, environmental)? |
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If yes, Please Specify |
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If the student has allergies, do they carry an Epi pen and/or allergy kit? (Allergy kits must be clearly marked with the student’s first and last name.) |
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| 2. Is the student taking any medications? |
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If YES, what is the name and purpose of the medication? If the student must take the medication during an Institute day, please bring a printed copy of the dosing instructions provided by your doctor on your Institute days. |
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| 3. Please list any special conditions or needs (dietary, medical, emotional, etc.) that Center staff should be aware of: |
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| 4. Primary Family Physician Name: |
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| 5. Primary Family Physician Phone: |
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| 6.. Health Insurance Company: |
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Parental Consent Information |
Field Trip Release:
I grant permission for my child to participate in field trips with the Center for Aquatic Sciences Teen Marine Science Institute. Center staff reserves the right to cancel/reschedule field trips if necessary. I understand that transportation to and from the program may be provided by CAS as a convenience
to mein the form of a bus provided by an outside company hired by CAS or a van or other vehicle operated by CAS personnel
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Photo Consent:
I consent to the taking of and use for promotional/programmatic purposes by the Center, Adventure Aquarium or their designates of my child's name, image, and likeness, as shown in photographs, social media, motion picture film and/or electronic images, and/or audio recordings made of my child's voice during the Institute. I understand if I consent that such materials shall be the sole property of the Center for Aquatic Sciences at Adventure Aquarium and there will be no remuneration received by me or my child.
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Medical Consent:
If my child needs emergency medical care and no one can be contacted, I give my consent for the transportation of my child by ambulance and for the administration of any treatment deemed necessary by licensed medical personnel.
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| If my child uses an epi-pen, I give permission for Center staff to administer the epi-pen in the case of an emergency |
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Release:
My child will be participating in the Teen Marine Science Institute operated by the Center for Aquatic Sciences at Adventure Aquarium.
I do hereby waive and release the Center, and its Trustees, officers, employees, agents and contractors, of any and all liability (including attorney fees and costs) arising out of or in connection with my child's participation in the Program and transportation associated with the Program. I agree to assume financial responsibility for all medical and hospital expenses.
I/We have carefully read the Teen Marine Science Institute Confirmation Information and Medical and Release statements and fully understand its contents.(Please Electronically Sign and Date Below)
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