Medical Release Form

We are required to have the following information for each child enrolled in the Discovery Program, Junior Historian, and Naturalist Leadership Program at least two weeks prior to the session’s start date.  Please submit the above information if you have not already done so as part of our online registration process.  Necessary forms include:

  • Medical Release Form
  • Health History Form (* provided by health care provider)
  • Current list of immunizations (* provided by health care provider)

If your healthcare provider has given you a form recording the most recent physical exam and all required immunizations, you can send that copy in lieu of this form.  If your healthcare provider has not provided you with a form recording the most recent physical and all required immunization, please complete the top information in our health history form (attached above) and send the form to your provider’s office to complete.

Please Note: NO child will be allowed to participate in our programs without our administration receiving ALL of the completed registration and medical information.  MMA reserves the right to cancel – without refund – any camper’s spot if the information is not received prior to two weeks before the session’s start date.

Please contact Whitney Morris, Discovery & Teen Program Director at wmorris@mariamitchell.org with any questions.  Thank you for helping us keep your children safe!

Participant Information:

Child's Name: *    Nickname:
Parent/Guardian Name(s): *
Date of Birth: *    Month   Day   Year           Age:
Island address:
Street/PO Box: *
Post Office: *     Zip: *
Phone: *    Cell Phone:
If you would like your child to be in the same section of a class as another child, please list their names here (requests will be filled when possible):

Physician & Insurance Information:
Child's Physician's Name: *   Phone Number:
Health Insurance Provider: *    Phone Number: *   
Subscriber Name:   Certificate Number:
Group Number:  

Emergency Contact:
Emergency Contact: * Phone Number: *   
Relationship: *  
   
Emergency Contact: Phone Number:
Relationship:  
 

Swimming Ability:
Are you comfortable with your child participating in water activities?   Yes     No *   
If yes, how would you rate your child's swimming abilities?

Participants General Health History:
Please list any medical concerns that your child may have in order to allow our teachers to provide the best possible experience for your camper.
Allergies (i.e. food, medicine, seasonal, environmental, etc):
Has the participant ever had or been treated for any of the following (Please check all that apply):
Surgery
Diabetes
ADHD/ADD
Recurrent/Chronic Illness
Seizures
Chest Pain
Recent Injury
Fainting
Asthma/Wheezing
If yes to any of the above, please explain in more detail below:
Emotional and/or Behavioral Issues:
Additional Information:

Medications:
Is your child currently taking any medication?   Yes     No *   
Medication: Dosage:
Medication: Dosage:
Medication: Dosage:

Pick-Up Form:
Please list all the possible people that may pick up your child.

*** Please be aware that MMA staff will be checking I.D.'s to ensure your child's safety. MMA will not allow your child to go home with anyone not on this list. Thank you.
Name:  * Phone Number:  *
Name: Phone Number:
Name: Phone Number:

Photo Release:
I agree that photos of my child may be used in MMA publications and advertising:  Yes     No *   

Sunscreen/Insect Repellent Release:
I give permission for my child to self‐apply sunscreen/insect repellent that I have provided. MMA staff will supervise children during this process. I will apply sunscreen/insect repellent to my child before arriving.
 Yes     No *   
 
I give permission for MMA staff to apply sunscreen/insect repellent that I have provided to my child. I will apply sunscreen/insect repellent to my child before arriving.
 Yes     No *   

Permission to Participate and Medical Release:
Being a parent or legal guardian of the above‐named minor, I do hereby appoint the Maria Mitchell Association and the Emergency Contact listed above to act in my behalf in authorizing emergency medical, dental or surgical care and hospitalization for the above‐named minor in the event that I cannot be reached. This document will be presented to a physician, dentist or appropriate hospital representative at such time as emergency medical, dental or surgical care or hospitalization may be required.

The person named below agrees to indemnify and hold harmless the Maria Mitchell Association, its agents and employees, from any and all liability, loss, damage, expense, causes of action, suits, claims or judgments for injury to the above mentioned child or other persons or the property resulting from or arising out of the participation of the above mentioned child as a Discovery Class Student, and shall at his/her own cost and expenses defend any and all actions or suits which may be brought against the Maria Mitchell Association, either alone or in conjunction with others, upon any such liability, claim, or claims and shall satisfy, pay and discharge any and all judgments, and fines that may be recovered against the Maria Mitchell Association in any such action or suit, provided, however that the Maria Mitchell Association shall give to the undersigned written noticed of any such claim or demand.
I have reviewed and approve the Permission to Participate and Medical Release stated above:
Name of Parent or Guardian approving this Medical Release:  *
Email Address:  *