Summer Adventures Liability Waiver - Stuhr Museum : Stuhr Museum

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Student Information

Child's Name(Required)

Child's Name

First Last

Parent/Guardian Name(Required)

Parent/Guardian Name

First Last

Relationship to Child(Required)

Relationship to Child

Phone Number(Required)

Phone Number

Alternate Contact Person(Required)

Alternate Contact Person

First Last

Relationship to Child(Required)

Relationship to Child

Phone Number(Required)

Phone Number

Allergy & Medical Information

Please indicate if your child has any of the following types of allergies:(Required)

Please indicate if your child has any of the following types of allergies:

Food Allergy

Insect Sting/Bite Allergy

Drug Allergy

Other Allergies

No Known Allergies

Please tell us more about this allergy, including severity of reaction and management/treatment needed: Food(Required)

Please tell us more about this allergy, including severity of reaction and management/treatment needed: Food

Please tell us more about this allergy, including severity of reaction and management/treatment needed: Insect Sting/Bite(Required)

Please tell us more about this allergy, including severity of reaction and management/treatment needed: Insect Sting/Bite

Please tell us more about this allergy, including severity of reaction and management/treatment needed: Drug(Required)

Please tell us more about this allergy, including severity of reaction and management/treatment needed: Drug

Please tell us more about this allergy, including severity of reaction and management/treatment needed: Other(Required)

Please tell us more about this allergy, including severity of reaction and management/treatment needed: Other

Will your child carry an Epi-pen during Summer Adventures?(Required)

Will your child carry an Epi-pen during Summer Adventures?

Yes

Does your child understand his/her allergies and take reasonable precautions to avoid the allergen(s)?(Required)

Does your child understand his/her allergies and take reasonable precautions to avoid the allergen(s)?

Yes

Is self-medication by Epi-Pen permitted and recommended for your child?(Required)

Is self-medication by Epi-Pen permitted and recommended for your child?

Yes

Does your child have any medical condition(s) we need to be aware of?(Required)

Does your child have any medical condition(s) other than the allergies listed above that we need to be aware of?

Yes

Please provide a brief description of the condition below. Please also include if your child will carry any medication or medical accessories with them.(Required)

Please provide a brief description of the condition below. Please also include if your child will carry any medication or medical accessories with them.

Stuhr Museum Summer Adventures staff MUST be notified when an Epi-Pen or other medical equipment is brought by a student. Medications must be in original container and clearly labeled with child’s full name, directions for administration and expiration date.

I hereby authorize Stuhr Museum employees and agents on my behalf to administer, attempt to administer, or allow my child to self-administer the lawfully prescribed Epi-Pen.

I understand that if Epi-Pen administration is necessary for my child, 911 Emergency Services will be called immediately, and the Parent/Guardian will be notified second. If the Parent/Guardian cannot be reached, the Alternate Emergency Contact will be contacted next.

I acknowledge that it may be necessary for the Epi-Pen medication to be administered to my child by an individual who is not a nurse or trained medical professional, and I specifically consent to such practice. I hereby waive any claim for myself, my heirs, executors, assigns, or personal representative that I might have against Stuhr Museum, its employees, officials, or agents from and against any and all claims, damages or causes of action arising out of or in any way connected to the self-administration, administration, failure to administer, or attempt to administer Epi-Pen medication to my child. I further agree to protect, indemnify, defend and hold harmless the Stuhr Museum, its employees, officials or agents arising out of or in any way connected to the self-administration, administration, failure to administer or attempt to administer Epi-Pen medication to my child.

I understand this form is for informational purposes only and will be destroyed after my child's participation in Summer Adventures 2023 has concluded. I also understand that myself or the alternate contact listed should be available at the phone number provided during my child's class in case Stuhr Museum needs to reach one of us.

Please type your first and last name in the box below to sign this form.(Required)

Please type your first and last name in the box below to sign this form.

Date(Required)

Date

MM slash DD slash YYYY

Summer Adventures Student Information & Liability Waiver

Student Information

Allergy & Medical Information