Impression 5 Emergency Release Form
Emergency release form for Impression 5 Science Center programming.
Child's Name (first and last name) *
Child's Date of Birth *
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Child's Address *
Parent/Guardian #1 Name *
Parent/Guardian #1 Phone Number *
Parent/Guardian #2 Name
Parent/Guardian #2 Phone Number
Additional Emergency Contact Name
Additional Emergency Contact Phone Number
Additional adults (first and last name) who may pick up my child from Impression 5. (All adults listed above are included in pick-up list.)
Child's Allergies *
Please describe any support needs for your child.
I understand that by sending my child to an Impression 5 Science Center L.A.B.S. camp, there is a risk of my child being exposed to COVID-19. *
Required
PHOTO RELEASE: Impression 5 will routinely publish in print, electronic, or video format the likeness or image of children enrolled in L.A.B.S. Programs in conjunction with Impression 5 programming and publicity. *
I give my permission for my child to participate in all the program-associated activities at the Science Center. I hereby authorize Impression 5 Science Center to seek emergency treatment for the child indicated above in the event that I cannot be reached.
Parent/Guardian Signature *
Today's Date *
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Submit
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