VDM Emergency Release Form
The following information is needed to provide responsible and proper medical attention while your child is in the care of Virginia Discovery Museum staff:
Child First Name *
Your answer
Child Last Name *
Your answer
Cell Number *
Your answer
Work/Home Number *
Your answer
Food Allergies *
Your answer
Medical Allergies *
Your answer
Other
Your answer
Emergency Contact Name & Number *
Your answer
Doctor's Name & Number *
Your answer
Hospital *
I waive all claims for myself, my heirs, or assigns against the Virginia Discovery Museum for any injury or illness which may result from my child’s participation in camps, including short walks on the Downtown Mall and grant the Virginia Discovery Museum staff the authority to take appropriate steps required in case of injury or emergency.
On behalf of my child and myself, I irrevocably consent to the unrestricted use by the Virginia Discovery Museum of my child’s photograph or likeness for advertising or promotional purposes, and I waive the right to inspect or approve such completed photographs, likeness, advertising, or promotional materials used in connection herewith.
Please type your name below to acknowledge the above statements *
Your answer
Please provide the date of form completion
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Thank you for completing this form!
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