EMERGENCY MEDICAL RELEASE FORM
The following information is needed to provide responsible and proper medical attention while your child is in our care:
Child’s Name: __________________________________________________________
Parent/Guardian: ________________________________________________________
Home #: ___________________________ Work/Cell #:________________________
Food Allergies: __________________________________________________________
Medical Allergies: _______________________________________________________
Other: _________________________________________________________________
Emergency Contact: _____________________________________________________
Daytime Phone #: _______________________________________________________
Doctor’s Name: _________________________________________________________
Doctor’s Phone #: _______________________________________________________
Hospital: UVA or Martha Jefferson
I hereby grant the Virginia Discovery Museum staff the authority to take appropriate steps required in case of injury or emergency and hold the Museum and its staff members harmless from any liability.