JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Impression 5 Emergency Release Form
Emergency release form for Impression 5 Science Center programming.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Child's First Name
(If they have a prefered nickname or shorting of their name, please include that)
*
Your answer
Child's Last Name
*
Your answer
Child's Date of Birth
*
MM
/
DD
/
YYYY
Child's Address
*
Your answer
Parent/Guardian #1 Name
*
Your answer
Parent/Guardian #1 Phone Number
*
Your answer
Parent/Guardian #2 Name
Your answer
Parent/Guardian #2 Phone Number
Your answer
Additional Emergency Contact Name
Your answer
Additional Emergency Contact Phone Number
Your answer
Additional adults (first and last name) who may pick up my child from Impression 5. (All adults listed above are included in pick-up list.)
Your answer
Child's Allergies
*
Your answer
Please describe any support needs for your child.
Your answer
I understand that by sending my child to an Impression 5 Science Center L.A.B.S. camp, there is a risk of my child being exposed to COVID-19.
*
YES, I understand and assume this risk.
Required
PHOTO RELEASE: Impression 5 will routinely publish in print, electronic, or video format the likeness or image of children enrolled in L.A.B.S. Programs in conjunction with Impression 5 programming and publicity.
*
YES, I release my child's likeness.
NO, I do not release my child's likeness.
I give my permission for my child to participate in all the program-associated activities at the Science Center. I hereby authorize Impression 5 Science Center to seek emergency treatment for the child indicated above in the event that I cannot be reached.
Parent/Guardian Signature
*
Your answer
Today's Date
*
MM
/
DD
/
YYYY
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Impression 5 Science Center.
Report Abuse
Forms
