Camp Permission Form Camper’s Name * Required First Last Age (as of June 1st) * RequiredBirth Date - must be mm/dd/yyyy format * Required Grade Entering * RequiredGender * RequiredParent/Guardian Name * Required First Last Email * Required Address * Required Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Camp(s) Attending * RequiredCamp NameStart DateAdd or remove row First Emergency Contact * Required Name Relationship to Camper Phone Second Emergency Contact * Required Name Relationship to Camper Phone Person(s) to whom the child may also be released to (in addition to Emergency Contacts)Only those listed will be allowed to sign our your child. Proper ID must be shown at time of pick up.NameRelationship to CamperPhoneAdd or remove row Is your child age 11–13 and allowed to sign him/herself in and out of camp? * RequiredYesNoMedical InformationPlease list any medications your child is taking now.Medication NameReason for TakingAdd or remove row Does your child need to take a prescription or over-the-counter medication during camp hours? * RequiredYesNoWill your child be self-administering any of these medications during camp? * RequiredIf YES, please fill out the Carnegie Museums of Pittsburgh Policy and Consent for Self-Administration of Medication form.YesNoAllergiesPlease note whether the allergy is an ingested or a contact allergy.AllergyReactionAdd or remove row Does your child carry an Epinephrine Auto Injector? * RequiredIf YES, and if you consent to emergency administration, please fill out the Carnegie Museums of Pittsburgh Epinephrine Auto Injector Policy and Consent form.YesNoWhat is the allergy? * RequiredDoes your child require allergen free seating? * RequiredYesNoDietary RestrictionsEmergency Medical InformationChild’s Physician/Medical Care Provider & Phone NumberOther Information You Think We Should KnowRelevant information may include: other medical conditions, mobility or other accommodations, learning disabilities, child’s primary language if not English, etc.Does your child use wraparound services during the school year? If yes, will they be attending camp with your child? If not, what are some helpful supportive strategies you can give us to help your child? Authorization for Camp Participation I authorize my child to participate in Carnegie Museum of Art and Natural History’s Summer Camps program. I release Carnegie Museums of Art and Natural History, two components of Carnegie Institute, from any and all claims, costs, and liabilities due to accidents, injury, or other harm to my child.Signature of Parent/Guardian * RequiredDate - must be mm/dd/yyyy format * Required Photo Release * RequiredI grant permissionI do not grant permissionto Carnegie Museums of Art and Natural History to use, reproduce, and/or publish for the promotion of Carnegie Museums of Art and Natural History and its programs (e.g. catalogs, magazines, website, videos, text panels, etc.), photographs and/or film footage taken during the summer. The use of these photographs is strictly limited for use by the Carnegie Museums of Art and Natural History. They will not be sold or reproduced for sale in any form.Signature of Parent/Guardian * RequiredDate - must be mm/dd/yyyy format * Required Behavior Agreement I understand that any child exhibiting behavior that may cause harm to themselves, other camps, or camp staff will be asked to leave the program without a refund. These behaviors include, but are not limited to, hitting, kicking, biting, sexual harassment, and/or possessing weapons or illegal substances.Signature of Parent/Guardian * RequiredDate - must be mm/dd/yyyy format * Required Late Pick-Up Policy Full-day campers ages 6+ not picked up by 3:15 p.m. will be considered enrolled in post-camp care. Parent/guardian will be charged the full weekly post-camp care fee of $75 per child. Post-camp care is not available for children under age 6. Parents/guardians of children enrolled in half-day camp or Hi Fives! programs will be charged $20 for every 15 minutes late. Parents/guardians of children enrolled in post-camp care will be charged $20 for every 15 minutes late (past 6 p.m.). Late pick-up and post-camp care fees must be paid before the following day of camp. Campers will not be permitted to attend camp until late pick-up fees have been paid. If a full-day camper has not been picked up by 6:30 p.m., or a half-day camper by 3 p.m. (morning session) or 6:30 p.m. (afternoon session), and museum staff are unable to contact a parent/guardian, staff will contact the Allegheny County Department of Human Services Office of Children, Youth, and Families. By signing below, I certify that I have read and understand the late pick-up policy.Signature of Parent/Guardian * RequiredDate - must be mm/dd/yyyy format * Required Would you like to receive daily e-mail updates during camp? * RequiredYesNoTo what e-mail address should the updates be sent? * Required NameThis field is for validation purposes and should be left unchanged.