Parent Authorization Form

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Please fill out a separate form for EACH child that will be attending.

Email *

Child's Name *

Child's Birthdate *

YYYY

Child's Age *

Guardian 1 Name *

Guardian 1 Phone Number(s) *

Guardian 2 Name

Guardian 2 Phone Number(s)

Email Address of Guardian(s) *

List Emergency Contacts and/or People Authorized to Pick Up Your Child (ID REQUIRED at pick-up)

(Please list full name and phone number(s))

Allergies/Behavior/Medication Notes

The following are HOSC's Policies and Agreements. Please read through these carefully and check "I Agree" to indicate your comprehension of and agreement with these policies.

HOSC Behavior Policy: By registering for this camp, you acknowledge and agree that all campers are expected to behave respectfully towards staff, fellow campers, and camp property at all times. Unacceptable behavior, including bullying, vandalism, violence (or threats of violence), theft, or disregard for safety rules, may result in disciplinary action (time out), up to and including immediate dismissal from camp, without refund, and may require further action in accordance with camp policies.

The Hands-On Science Center (HOSC) does not discriminate on the basis of race, color, sex, handicap, religion, or national origin. HOSC reserves the right at its sole discretion to refuse an application or dismiss a child from camp. No refund will be made of fees if the child has attended any portion of the camp period.

I give the Hands-On Science Center permission to photograph and/or videotape my child for public relations and/or marketing purposes. Photos will remain archived at the Hands-On Science Center for promotional purposes without notification.

I authorize the camp management to act as the agent of the parents in any emergency or to administer basic first aid for the health and welfare of the camper involved. I am responsible for the expenses involved if the services of a physician or hospital are required.

I authorize the camp management to act on my behalf in administering medications that I have provided for my child during camp hours.

I agree

Other:

Required

In lieu of a signature, please type your name in the space provided to indicate that you were the person to complete the above information and that it aligns with your intentions to comply with the policies and rules of the Hands-On Science Center. *

Send me a copy of my responses.

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