Health & Release Form 2022
Please fill out this form for each child that you are registering for Camp Innovation (HP STEM Camp).
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Child's First Name *
Child's Last Name *
Gender *
Birthdate *
MM
/
DD
/
YYYY
Grade your child will enter in September 2022: *
Parent/Guardian # 1 First Name *
Parent/Guardian # 1 Last Name *
Parent/Guardian # 1 Address (Street Name, Town, State, Zip Code) *
Parent/Guardian # 1 Phone Number (Home) *
Parent/Guardian # 1 Phone Number (Cell) *
Parent/Guardian # 1 Email Address *
Parent/Guardian # 2 First Name (Optional)
Parent/Guardian # 2 Last Name (Optional)
Parent/Guardian # 2 Address (Optional)
Parent/Guardian # 2 Phone Number (Optional)
Parent/Guardian # 2 Email Address (Optional)
Emergency Contact First Name *
Emergency Contact Last Name *
Emergency Contact Phone Number (Home) *
Emergency Contact Phone Number (Cell) *
Emergency Contact Email Address
Emergency Contact- Relation to Child *
Please list those people in addition to parents/guardians who are permitted to pick up your child: *
Does your child have permission to walk/ride bike home alone? *
If you answered Yes to the above question, please sign your name here.
Child’s Primary Physician *
Primary Physician Address *
Primary Physician Phone Number *
Please list any medical problems, including any requiring maintenance medication (i.e. Diabetic, Asthma, Seizures). If none, please write None. *
Is your child allergic to any type of food or medication? If none, please write None. *
Please read and sign your name below. I understand that I will be notified in the case of a medical emergency involving my child. In the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured or becomes ill. *
Please read and sign your name below. Photo Release: I hereby give permission for my child to be photographed during the Harrington Park STEM Camp. I understand the photos will be used to keep a journal of activities, to share during powerpoint presentations and for promotional purposes including flyers, brochures, newspaper and on the internet.  I understand that although my child’s photograph may be used for advertising, his or her identity will not be disclosed, I do not expect compensation and that all photos are the property of Harrington Park STEM Camp. *
Please read and sign your name below. The Harrington Park STEM Camp and its co-organizers are not responsible for lost or damaged personal property. I understand that no fees will be refunded or transferred unless a child is unable to participate due to an accident or illness per physician orders. Children's’ photos and quotes may be used for publicity purposes. In case of an emergency, and if a family physician cannot be reached, I hereby authorize my child to be treated by Certified Emergency Personnel (i.e. EMT, First Responder, and/or Physician). *
Is there any other information that you would like to tell us about your child?  Please feel free to share any information that would help make this an amazing experience for your child.
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