3. 

5. Summer Camp Required Health and Supplemental Information

7. Name of Camp*
   -- Select One --Junior Paleontologist (entering grades 5 - 6)Protectors of the Patuxent (entering grades 3-4)Reptiles and Amphibians (entering grades 1-2)Marsh Detective (entering grades 1 - 2)
8. Child's Name (Last)*
9. Child's Name (First)*
11. Date of Birth*
    Date of Birth
12. Age at start of camp*
14. Address1*
16. Address2
18. City*
19. State*
20. Zip*
22. Parent/Guardian Name (First and Last)*
23. Home Phone
25. Work Phone
26. Cell Phone
28. Parent/Guardian Email*
32. Emergency Contact Information
34. Name 1*
35. Relation*
37. Home Phone
38. Work Phone
39. Cell Phone
41. Name 2
42. Relation
44. Home Phone
45. Work Phone
46. Cell Phone
50. Medical Information
52. Primary Care Physician*
53. Physician's Phone number*
55. Health Information*

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

57. Is child enrolled in a Maryland school?

    1. Yes

    1. No
58. If "yes" what is the name of the school?
60. 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?
    
    

    1. Yes
    2. No
62. 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.

66. 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. I also grant my permission to use any photographs of my child taken during camp for promotional purposes. NOTE: This release does not obligate your child to attend any or all scheduled trips or activities.
67. Waiver Release Agreement*

    By checking the box marked "I Agree" you are agreeing to the Waiver Release.

    1. I Agree
71. 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 school/center and inform the director with 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.

72. Sign Out Release Agreement*

    By checking the box marked "I Agree" you are agreeing to the Sign Out Release.

    1. I Agree
76. Authorized Persons for Pick-Up
    Remember: You are responsible for ensuring the list is updated and accurate.
78. Name 1*
79. Phone Number 1*
81. Name 2*
82. Phone Number 2*
84. Name 3
85. Phone Number 3
87. Name 4
88. Phone Number 4
92. UN-Authorized Persons for Pick-Up
    Remember: You are responsible for ensuring the list is updated and accurate.
93. 1. Does Not Apply to my child
95. Name 1
96. Phone Number 1
98. Name 2
99. Phone Number 2
103. Parent/Guardian signature*

     By electronically signing this document, you assert that all of the above information is true and accurate. 

104. Date Completed*
Leave This Blank:


106. 1. Receive an email copy of this form.
107. Email address

     This field is not part of the form submission.

108. Submit Submit and Print

* indicates a required field