Summer Camp Health Form

Student Information

Full Name *

Date of Birth *

Grade *

Camp Session Dates *

Please put all you are currently planning to attend. Dates can be adjusted later if you choose to attend more sessions.

Guardians Information

Guardians's Name *

Email *

Phone *

Relationship to the Student *

Emergency Contacts

Persons listed must be reachable during camp hours. List contacts in order of who to contact first.

Full Name *

Phone *

Relationship to the Child *

Full Name *

Phone *

Relationship to the Child *

Medical Information & Special Consideration

Fill out any that apply to your child. With Awarness of your child's special needs, staff may be able to modify activities and Techniques for inclusiveness prior to the start of camp.

Medical or behavioral conditions *

No Specific medical or behavioral conditions
Food allergies
Non-food allergies
Any physical, emotional or bahavioral conditions, including cognative, LD, ADD, ADHD, or autism requiring medication, treatment, special restrictions or condiferations while at camp.

My child is currently taking medication. *

Yes
No

Health Insurance/ Physician

Insurance Company

Policy/Group Number

Participant ID Number

Physician's Name

Office Phone

Date of last Tetanus shot

Immunizations: Are the child's immunizations current?

Yes
No

Please list an major medical treatment within the last year:

Permission To Secure Treatment

Camp staff are available who are trained in First Aid, CPR, AED, EpiPen, and asthma inhaler assistance. They will take whatever emergency medical measures are deemed necessary for the protection and safety of the camper within their training.

In the event of any emergency, I authorize the Sci-Tech Discovery Center to secure from any licensed hospital, physician, and/or medical personnel any treatment deemed necessary for me or my minor child/ward’s immediate care and agree that I will be responsible for payment of any and all medical services rendered. I understand that this authorization includes transporting my child by ambulance if necessary to the nearest medical treatment facility if I am unable to be reached first. I will not hold the Sci-Tech Discovery Center responsible for personal injury, death, or loss of property.

Signature *

Clear Signature

Photo Release

Photo Release *

Yes, I give permission for my child's picture to be used in marketing and social media for Sci-tech Discovery Center.
No, I do NOT give permission for my child's picture to be used in marketing and social media for Sci-tech Discovery Center.

Sick Policy

Student with a fever must stay home.

Students with mild sysmptoms (sneezing, runny nose, slight cough) may attend camp, but must wear a mask.

Sick Policy *

I agree

Food Policy

Students must bring their own lunch, snack & water bottle.

All food items must be nut free.

Food Policy *

I agree

Program Status Disclosure

Sci-Tech Discovery Center offers educational camps and enrichment programs that are exempt from licensing by the Texas Health and Human Services Commission (HHSC). Sci-Tech Discovery Center is not a licensed child care provider and is not regulated as a licensed child care operation under Texas law.

By signing below, I acknowledge that I have been informed of and understand that Sci-Tech Discovery Center operates as an HHSC-exempt program and not as a licensed child care vendor.

Assumption of Risk and Acknowledgment

I understand that participation in Sci-Tech Discovery Center programs may involve hands-on activities, movement, use of materials, and group interaction. While staff take reasonable steps to maintain a safe environment, I acknowledge that some physical risks are inherent in camp and educational activities, including but not limited to:

• Minor cuts, scrapes, or bruises

• Slips, trips, or falls inside or outside the facility

• Muscle strains or soreness from physical movement or active games

• Injuries related to age-appropriate science activities or equipment use

• Allergic reactions due to environmental exposure (e.g., materials, outdoor elements)

• Accidental contact with other participants during group activities

Release and Permission

I voluntarily allow my child to participate in Sci-Tech Discovery Center programs and assume responsibility for any risks associated with participation, except in cases of gross negligence or willful misconduct.

I confirm that I have had the opportunity to ask questions and that I understand the information provided in this acknowledgment.

Program Status Disclosure *

I agree

Signature of Parent *

Clear Signature

Printed Name *

Date of Signature *