Maria Mitchell Association

Medical Release and Pick-up Form - Discovery Classes 2010

Having trouble with the online form? Not the child’s parent or legal guardian? Click here to download and print a copy of this medical form. Please mail completed forms to: Maria Mitchell Association Attn: Education Director 4 Vestal Street Nantucket, MA 02554

Click here to view or print the parent letter (a copy will be emailed to you after your registration is complete)

Medical Release

Information

Child's full name:
Age:	DOB:	Nickname:
Parent/Guardian Names:
Island Address:
Island Phone:		Cell Phone:
Emergency Contact:		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):

Medical Medical Concerns
Please list any medical issues including allergies, emotional and/or behavioral issues your child may have in order to allow our teachers to provide the best possible experience for your child.

Medication
Please list all medications and dosage your child is currently administered. If your child needs to take any medication (including Epi-Pens) while participating in a Discovery class you must complete and attach an Authoriazation to Administer Medication form.

Medication:	Dosage:
Medication:	Dosage:

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 undersigned hereby 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 notice of any such claim or demand.

Printed Name of Parent/Guardian:
Signature:	Date:

Pick-Up Form

People Authorized to Pick-Up

Please list all the possible people that may pick up your child. Please make them 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:
Name:	Phone:
Name:	Phone:
Name:	Phone:
Name:	Phone:

Photo Release By initializing this section I agree that photos of my child may be used in MMA publications and advertising.

Sunscreen/Insect Repellent Permission

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