The Science Zone Camp Emergency Contact and Medical Release Form

The Science Zone

222 E. Collins Dr

Casper, WY 82601

(307) 473-9663

TheScienceZone.org
The Science Zone Camp Emergency Contact and Medical Release Form
Student Name*
Age*
Gender
DOB*

MonthDayYear
Date
Address*
Emergency Contact 1*
Phone*
Emergency Contact 2*
Phone*
Current Physician
Dentist
Health Insurance Co
Policy Number
Name of Member
Allergies*
Medical conditions*
Medications: Is the student currently taking any medication? If yes, please list:
Emergency Medications: Include any medications that may be necessary to have administered to your child. Include specific details and instructions regarding dosage, timing, or situations Any such medications need to be given to staff members for storage during camp.

Medical Release: The health history is correct SO far as I know, and the person described has permission to engage in all prescribed camp activities except as noted. In case of Medical Emergency, if I cannot be contacted, I hereby give permission to a camp representative and the physician he/she selects to secure proper treatment, including: hospitalization, ordering injections, giving anesthesia, x-rays, routine tests, treatment, transporting of child, or performing operations as may be urgently necessary for this child and to release reports necessary for insurance purposes for my Child noted above. This form may be copied for emergency purposes. I understand that every effort will be made to contact the camper's responsible parent or guardian. I further understand that if I do not have medical insurance that covers all costs, I will be responsible for such medical costs.

Liability Release: In consideration of being permitted to participate in any way in the activities at and to attend The Science Zone’s camps, I, for myself, my child, my heirs, personal representatives or assigns, do hereby release, wave, discharge, and covenant not to sue The Science Zone, J&P LLC DBA as Hole in the Wall Ranch, it’s officers, employees, and agents, from liability from any and all claims including the negligence of The Science Zone, its officers, employees, and agents, resulting in personal injury, accidents or illnesses (including death), and property loss arising from, but not limited to, the activities and attendance at or with The Science Zone. The participation in activities at The Science Zone carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries. Activities at The Science Zone require a high level of physical fitness, I warrant that my child is physically fit and able to participate in all Camp Activities. I also agree to INDEMNIFY AND HOLD HARMLESS The Science Zone, its officers, employees, and agents, from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorney's fees, as a result of my child's attendance and involvement in any activities at The Science Zone, including any claim asserted by my child after he/she become an adult. I also acknowledge that I have read the above and understand that I am giving up substantial rights, including the right to sue. I acknowledge that I am signing freely and voluntarily, and intend by my signature to a complete and unconditional release of all liability to the greatest extent allowed by law.

By Signing this document, I agree to the above listed terms and conditions.
Parent/Guardian Signature*
Date*

MonthDayYear
Should be Empty: