Parent/Guardian Name

Participant's Name

Age

T-Shirt Size (Youth)
XSSMLXL

Mailing Address

Email Address

Phone Number

Terms of Service
In consideration for the Santa Maria Valley Discovery Museum [SMVDM] accepting my child’s entry into this camp/program, I personally, and on behalf of my child, accept all risks and hazards incidental to the conduct of the activity.  In my absence, I allow SMVDM staff to physically assist my child if he/she is in imminent danger. 

I also further acknowledge and agree that my child(ren) will be removed from the program upon any improper conduct or incident as determined by the SMVDM solely at its discretion. In the event that the SMVDM notifies me that my child must be removed from the program, I agree to immediately pick up and remove my child from the premises. I understand that I must pick up my child promptly at the end of class time and will be charged a $1.00 per minute late fee. My child will not be allowed to use the SMVDM equipment or exhibits without my
supervision before or after program hours.
I also give SMVDM my permission to take my child’s photograph and publish it.

I agree to the above conditions

Physician's Name

Physician's Phone Number

If I/we cannot be reached in case of an emergency, I/we authorize SMVDM staff to act on my behalf in obtaining medical care for my child and authorize the SMVDM to seek emergency assistance through 911.

I certify that the above information is true and correct.