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SC State Museum Release Form
Please fill out this form for each individual camper attending SC State Museum Camp
38
Questions
START
HIPAA
Compliance
1
Camper Name
*
This field is required.
First name AND Nickname
Last Name
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2
Camper Age
*
This field is required.
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3
Camper Birthday
We just really like birthdays and to celebrate them if they have one while with us.
/
Date
Month
Day
Year
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4
Are your child's immunizations current?
*
This field is required.
Yes
No
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5
Does your camper have any learning disabilities or difficulties with hearing, speech, or vision?
*
This field is required.
Yes
No
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6
If Yes, Please explain.
Reminder: Museum staff cannot administer medication.
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7
Does your camper have any mobile disabilities or physical limitations?
*
This field is required.
Yes
No
Camper will need to borrow a wheelchair
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8
If Yes, Please explain.
Reminder: museum staff cannot administer medication.
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9
Any medications or significant allergies?
*
This field is required.
Reminder: Museum staff cannot administer medication.
Yes
No
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10
If Yes, Please explain.
Museum staff are not permitted to administer medications. We CAN remind campers of their medication times and will send a text once they have self-administered any medication sent with them. Please let us know if they will be self-administering any medications. It's also helpful to know if they are on a new medication that will make them nauseous or drowsy.
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11
Is there anything you think we should know about your camper that may help us give them the best experience possible?
This includes things like a pet recently passing away, changing schools in the fall, Grandma in town and staying up late :) - anything that may make their "normal" a little less normal. You can also text us "handle with care" and your camper's name and we won't ask any questions at all. (803)528-2706
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12
Primary Care Physician’s Name
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13
Primary Care Physician’s Phone Number
Area Code
Phone Number
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14
Preferred Hospital of Choice
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15
Emergency Contact #1
*
This field is required.
Please use legal names and not nicknames. We will contact in order so contact 1 will be texted or called first.
First Name
Last Name
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16
Main Number/Cellphone We Can Text
*
This field is required.
Area Code
Phone Number
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17
Alternate Contact Number
Area Code
Phone Number
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18
Relationship to Camper
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19
Emergency Contact # 2
Please use legal names. This is the second person we will attempt to contact.
First Name
Last Name
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20
Main Number/Cell Phone We Can Text
Area Code
Phone Number
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21
Alternate Contact Number
Area Code
Phone Number
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22
Relationship to Camper
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23
Authorized Pick-up List Acknowledgment
*
This field is required.
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24
Authorized Pickup #1
*
This field is required.
Please only use legal names found on this individual's photo ID.
First Name
Last Name
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25
Relationship to Camper
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26
Authorized Pickup #2
Please only use legal names found on this individual's photo ID.
First Name
Last Name
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27
Relationship to Camper
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28
Authorized Pickup #3
Please only use legal names found on this individual's photo ID.
First Name
Last Name
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29
Relationship to Camper
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30
Authorized Pickup #4
Please only use legal names found on this individual's photo ID.
First Name
Last Name
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31
Relationship to Camper
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32
Authorized Pickup #5
Please only use legal names found on this individual's photo ID.
First Name
Last Name
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33
Relationship to Camper
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34
Are there any special circumstances we need to know about?
*
This field is required.
Example: Because of custody reasons, someone is only allowed to pick up on certain days.
Yes
No
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35
If Yes, Please explain.
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36
Final Step: Signature Authorizing This Form
*
This field is required.
Please type your name here and you'll be asked to sign next.
First Name
Last Name
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37
Signature
*
This field is required.
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38
Terms and Conditions
*
This field is required.
By checking the box below, you agree to the Terms and Conditions.
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Camps Release
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