Name of Camp:	___________________________________
Name of Child	__________________________________________________________
Name of Parent	__________________________________________________________
Home Address	__________________________________________________________
City, State	_______________________	Zip	__________Email: _________________
Home Phone:	_______________________	Daytime Phone: _______________________
Grade child will Enter in Fall Child's School		_______________________
50% Deposit Due at Registration			____I give permission for my child to be photgraphed during camp. ____I DO NOT give permission for my child to be photgraphed during camp.
Please return completed Registration and Medical Consent form to:
Drake Planetarium 2020 Sherman Ave. Norwood, Ohio 45212		Tel: 513-396-5578, Fax: 513-396-6486 Email: csteger@drakeplanetarium.org Visit us on the Web at www.drakeplanetarium.org

		Medical Consent Form
Name	___________________________	Address	___________________________	Phone	_____________________
Emergency Medical Authorization Purpose: To enable parents & guardians to authorize the provision of emergency treatment for children who become ill or injured while under school authority when parents or guardians cannot be reached. PART I OR PART II MUST BE COMPLETED.
		PART I: TO GRANT CONSENT
In the event reasonable attempts to contact me at home phone___________________ or mother's work phone___________________ or father's work phone ___________________ have been unsuccessful, I hereby give my consent for: 1. The administration of any treatment deemed necessary by the preferred physician Dr. ___________________at ___________________ (phone) or the preferred dentist Dr.___________________ at ___________________(phone) or in the event the designated practitioner is not available, by another physician or dentist. 2. The transfer of the child to the preferred hospital ___________________ or any hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinions of 2 other licensed physicians or dentists, concurring with the necessity for such surgery, are obtained prior to the performance of surgery.
FACTS CONCERNING THE CHILDS' MEDICAL HISTORY INCLUDING ALLERGIES, MEDICATIONS AND ANY PHYSICAL CONDITIONS TO WHICH THE PHYSICIAN AND SCHOOL SHOULD BE ALERTED: ___________________ _________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Signature of parent or guardian		_____________________________________		Date	___________________
PART I: REFUSAL TO CONSENT (do not complete Part II if you completed Part I)
I do not give my consent for emergency medical treatment of my child. In the event of any illness or injury requiring treatment, I wish the school authorities to take no action or to:___________________ _________________________________________________
______________________________________________________________________________________________
Signature of parent or guardian		_____________________________________		Date	___________________