BACKUP EMERGENCY CONTACT INFORMATION* *REQUIRED – must be someone who does not live with the camper. Please provide contact information for other people who know your camper and with whom we can consult if we cannot reach you. This person(s) is also authorized to pick up my child.

Permission Slip for Release of Child to Authorized Pickup *REQUIRED – Please complete this Field for us to release your child for pickup. Please include yourself if you will be picking up your child. Your child will not be released without proper identification of authorized pickup.

Person 1

Person 3

Authorization for Consent to Medical Treatment of

Minor Child

*REQUIRED – Please complete this Field for us to release your child for pickup. Please include yourself if you will be picking up your child. Your child will not be released without proper identification of authorized pickup.

If your child needs emergency medical care and you aren’t available to give formal consent to medical authorities, care may be unnecessarily delayed. To protect your child, leave a completed EMERGENCY CONSENT FORM with Nasri STEM Camp staffers. In the event of a medical emergency, this form should accompany your child to the hospital. I/we hereby authorize Nasri Academy for Gifted Children to give consent for all medical and/or surgical treatment that may be required for our child during our absence.

YES (please initial)

PHYSICIAN INFORMATION

INSURANCE INFORMATION Is the camper covered by family medical insurance?

ALLERGIES

(WE ARE A PEANUT AND TREE NUT FREE CAMP)*

ADDITIONAL INFORMATION

Please list ALL prescription medication, over-the-counter and non-prescription drugs taken routinely. Fill in the blanks completely. All drugs must remain in the original container. All prescription medications must be in a pharmacy-labeled container with the camper’s name on it. Loose pills and samples will not be accepted.

Bring ONLY enough medication to last 5 days.

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(Use a separate sheet if necessary.)

Permission to Use Photograph and Video Media

I grant Nasri Academy for Gifted Children, its representatives and employees, the right to take photographs and video of me and/or my children in connection with the above-identified organization. I authorize Nasri Academy for Gifted Children to use and publish the same in print and/or electronically.

I agree that Nasri Academy for Gifted Children may use such photographs and videos of me with or without my name and for any lawful purpose, including: publicity, illustration, advertising, and Web content.

PARENT/GUARDIAN AUTHORIZATIONS

The information given in this form is complete and accurate to the best of my knowledge. I hereby give my permission for my camper to participate in all camp activities. I have received, reviewed, and agree to follow the policies and information outlined in the Parent Handbook.

After finishing the form, press Submit button to Payment Page