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YOUTH CAMP HEALTH HISTORY FORM (CAMPER)

  1. CMM_Logo_CMYK
  2. Summer Camp Required Health and Supplemental Information

  3. Emergency Contact Information
  4. Medical Information
  5. Please list any information of which staff should be aware to help create a positive camp experience for your child (medical, behavioral, emotional, etc.). 

  6. Is child enrolled in a Maryland school?
  7. If "yes" what is the name of the school?
  8. Immunizations*

    For campers who currently reside within the United States, a United States territory, or the
    District of Columbia: Does the camper have any immunization exemptions because of a
    parental or guardian objection or medical contraindication?

  9. Non-Maryland Students

    If camper is not registered in a Maryland school, you must furnish the Calvert Marine Museum required records of immunization, contraindication statement from child's physician or exemption by religious belief statement before child can be admitted to the program.

  10. Waiver Release

    I hereby give permission for my child to participate in all activities and attend all trips sponsored by the Calvert Marine Museum. In consideration of the museum's accepting my child into this program, I agree to waive and forever discharge Calvert County, its employees and agents harmless of & from any injuries sustained by my child which occurs while enroute to or from or participating in any activity sponsored by the aforementioned parties. NOTE: This release does not obligate your child to attend any or all scheduled trips or activities.

  11. Waiver Release Agreement*
    By checking the box marked "I Agree" you are agreeing to the Waiver Release.
  12. Photo Release Waiver

    I grant Calvert Marine Museum permission to use photographs of above named child for any legal use. I acknowledge that this includes but is not limited to: publicity, copyright purposes, illustration, advertising, publication on the internet, and any communications related to the mission of Calvert Marine Museum. I further acknowledge that I will not be compensated for these uses and that Calvert Marine Museum owns all rights to the uses of these photos. I understand that by checking “I do not agree” my child will not be included in any group or other associated camp photos that are sent out to parents and/or guardians throughout the week.

  13. Photo Release*

    By checking the box marked "I agree", you are agreeing to the Photo Release

  14. Sign Out Release

    Upon dropping off and picking up my child from the camp, I agree to inform the camp leader and sign the appropriate form, including date and time I dropped off and picked up my child. In the event I am unable to pick up my child, I agree to call the museum and inform the camp leader of the name of the individual I authorize to pick up my child. I agree to provide the Calvert Marine Museum with the names of individuals I authorize to pick up my child when I am unable to do so myself. (See names listed below.) I realize it is my responsibility to keep this list updated and accurate.

  15. Sign Out Release Agreement*
    By checking the box marked "I Agree" you are agreeing to the Sign Out Release.
  16. Authorized Persons for Pick-Up
    Remember: You are responsible for ensuring the list is updated and accurate.
  17. UN-Authorized Persons for Pick-Up
    Remember: You are responsible for ensuring the list is updated and accurate.
  18. By electronically signing this document, you assert that all of the above information is true and accurate. 

  19. Leave This Blank:

  20. This field is not part of the form submission.