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Exploration.org

CONSENT AND DISCLOSURE FORM
Exploration Place, Inc.
Participant’s Name _______________________________________________________ Birth Date____________________ Parent/Guardian Name_____________________________________________________ Sex M F (circle one) Address_____________________________________________ City________________ State ________ Zip Code_________ Day Phone _______________________________________Alternate Phone _______________________________________ Person to notify in case of emergency, other than above: Name________________________________________________ Day Phone _______________________________________ Alternate Phone _______________________________________ Name of Family Physician __________________________________ Phone # ______________________________________ 1. Does participant have any significant illness or disability that would in any way prevent or limit full participation in camp activities? _____ yes ______ no. If yes, please explain __________________________________________________ ______________________________________________________________________________________________________ 2. Please check if participant has or has had any of the following: _____ diabetes _____ epilepsy _____ kidney problems _____ rheumatic fever _____ tuberculosis _____ other 3. Has participant had any other significant illnesses, injuries, or surgeries? _____ yes ____ no. If yes, please explain. ______________________________________________________________________________________________________ 4. What routine medications and their dosages does the participant take? ______________________________________________________________________________________________________ 5. Please list the date of the last immunization for: Tetanus________________ MMR____________ Chicken pox_______ 6. Is participant allergic to any medication? ____ yes _____ no. If yes, please list ________________________________ 7. Does participant have any other allergies? _____ yes ____ no. If yes, please list _______________________________ 8. My child may be given the following over-the-counter medications if my child needs them, without contacting me: Acetaminophen (generic Tylenol) ________ Antihistamine (generic Benadryl) _____________ Ibuprofen (generic Motrin) _____________ Antacid (generic Tums, Pepto-Bismol, etc) ______ Dimenhydrinate (generic Dramamine) ________ Neosporin ________________________________ Other ____________________________________ 9. Does participant have any dietary restrictions? ____ yes _____ no. If yes, please list: ___________________________________________________________________________________________________ Continued
HOLD HARMLESS AND RELEASE
By signing this document, I hereby authorize the use of the information on this form for medical treatment
of the participant, and I authorize the release of this information to the named insurance company as
needed, in presenting any claim for benefits. I have the right to revoke this consent at any time except
where Exploration Place, Inc. has already used or disclosed such health information in reliance on this
Consent form.
I am aware of all the inherent damages and risks involved in this Exploration Place, Inc. program including:
bodily injury, sprains, fractures, dislocations, lacerations, concussions, skin disease, eye, head, neck or
back injuries, or death. I give the participant the permission to participate in all activities of this program.
I understand that Exploration Place, Inc. does not provide any Accident or Medical Insurance and that I am
required to provide any medical insurance for the participant. I agree to be financially responsible for all
medical expenses whatsoever.
I agree, on behalf of myself, the participant, my assigns, executors and heirs, to release, indemnify and
hold harmless Exploration Place, Inc. and its directors, officers, agents and employees from any and all
liability, damage, or claim of any nature arising out of or in any way related to the participant’s
participation in this program, except claims or losses caused by the sole gross negligence of Exploration
Place, Inc.
5. I understand this Agreement to be a Release of all claims and causes of action for participant’s injury or
death or damage to participant’s property that occurs while participating in the described activity and it
obligates me to indemnify the parties named for any liability for injury or death of any person and damage
to property caused by the participant’s negligent or intentional act or omission.
Parent’s Signature ___________________________________________ Date _____________________________________ The participant has Health Insurance yes
(circle one)
*If yes, please include a copy of the front and back of the card. CONSENT FOR TREATMENT OF A MINOR

I hereby give my consent for treatment of
______________________________________________________________________________________________________ This authorization covers initial first aid provided by Exploration Place staff, or any medical procedure, which may be deemed advisable by a licensed medical physician, including emergency medical attention and treatment. The undersigned verify that the above health insurance billing information is true and correct to the best of his/her
______________________________________ _________________________ __________________________
Signature of person authorized to give consent Relationship to Participant Date

____________________________________________________________________________________

Address (if different than Participant’s)
Return to:

Source: http://www.exploration.org/files/Consent%20and%20Disclosure%20Form.pdf

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