Health and Consent Form

Camper Information

Camper First Name *

Camper Last Name *

Date of Birth *

Grade Entering this Fall *

Gender *

Address (line 1) *

Address (line 2)

City

State

Zip Code

Dietary and special needs, allergies or medications (please list)

Contacts

Parent/Guardian Name *

Relationship to Camper *

Email *

Phone *

Emergency Contact *

Relationship to Camper *

Phone *

Physician’s Name *

Practice Name *

Phone *

In case of emergency, the Science Center of Iowa will take your child to Mercy Hospital in Des Moines. If you do NOT want them to go to Mercy, where do you want them sent?

Other adults authorized to pick up your camper

Please select all of the camps your child will be attending from the list below.

All Grades- Extended Care and Lunch

			Members	Non-Members

Dec26

All Day

$$6-$10

Dec27

All Day

$$6-$10

Dec28

All Day

$$6-$10

Dec29

All Day

$$6-$10

Winter- Grade 4th-6th

			Members	Non-Members

Dec26

All Day

$65

$70

Dec27

All Day

$65

$70

Dec28

All Day

$65

$70

Dec29

All Day

$65

$70

Winter: Grades 2-3

			Members	Non-Members

Dec26

All Day

$60

$70

Dec27

All Day

$65

$70

Dec28

All Day

$65

$70

Dec29

All Day

$65

$70

Winter: Kindergarten – 1st Grade

			Members	Non-Members

Dec26

All Day

$65

$70

Dec27

All Day

$65

$70

Dec28

All Day

$65

$70

Dec29

All Day

$65

$70

Parents must agree to the following to finalize camp registration.

(Optional) Yes SCI has my permission to take photos of my camper that may be used for marketing purposes. I understand that if I answer no to this question no images will be taken of my camper for any reason.

I understand that while field trips are not guaranteed as part of camp they are used to support learning. If my camper is scheduled for a field trip they will be driven in a SCI vehicle by camp staff trained to operate this vehicle. If I object to my camper going on a field trip I will not send them to camp on that day.

I understand SCI Summer Camps are taught by college students or recent graduates that have been studying Education and/or Science.

I understand SCI campers will be learning about the topic of the camp title. If there is time to explore the rest of the museum, then the camp will do so. Otherwise, the campers will be focused on learning the subject at hand.

I understand that after May 1 no refunds will be issued for camp without a documented medical reason accompanied by a doctor's note.

I understand that health forms are good for one calendar year and that should my camper's health information change it is my responsibility to inform SCI by filling out a new health form.

I understand that SCI is not responsible for personal items my camper brings such as electronic devices, games, cell phones, money, etc.

I am aware of the camp's starting and ending times (AM Camp 9:00 AM - 12:00 PM and PM Camp 1:00 PM - 4:00 PM) and will drop off and pick up promptly. I realize that if my child arrives late, they may miss their fieldtrip and will be placed with another camp for that day.

I am aware of what time extended care starts and ends (Before Care 7:30 AM - 9:00 AM and After Care 4:00 PM - 5:30 PM) and will drop off and pick up promptly.

I understand that a $10 fee will be assessed for every 15 minutes that a camper remains after the pick-up time.

I understand the Science Center of Iowa Camp Program supports Chapter 232 of the Iowa Code and that SCI requires that all employees who are mandatory reporters under this Chapter be familiar with the requirements therein.

(Optional) Yes, My child is in 5th-8th grade and can sign themself in and out of camp.

Please indicate where your camper is to wait for you for pick-up. For those 5th-8th graders allowed to sign themselves out of camp, they must go directly to the designated pick-up location listed below. They are not allowed to explore SCI after camp unless accompanied by an adult. *

Other Information

We want your child to have the best possible experience at camp! Please share any information below about your camper that will help us to assist them with a successful day at SCI: *

I understand and agree that the above information is correct.

Signature (your name) *

Age	Non-Members	Members
Adults (13-69)	$15	FREE
Children (2-12)	$15	FREE
Senior (70+)	$13	FREE