Emergency Release Form

Child's Name *

Date of Birth *

Year

Month

Day

Child's Address *

City *

State *

Zip *

Parent’s/Guardian’s Name *

Phone No. *

Parent’s/Guardian’s Name

Phone No.

Additional Emergency Contact *

Phone No. *

Additional adults who may pick up my child from Impression 5

Insurance Company

Insurance Number

Allergies

Comments (please continue on back if necessary)

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.

PHOTO RELEASE OPTION *

YES, I release my child’s likeness.

NO, I do not release my child’s likeness.

I hereby authorize Impression 5 Science Center to seek emergency treatment for the child indicated above in the event I cannot be reached. I give my permission for him/her to participate in all activities in the Science Center as part of the described programs.

Parent/Guardian Signature *

Printed Name *

Date *

Year

Month

Day

Impression 5
Science Center

200 Museum Drive, Lansing, MI 48933 517.485.8116

MONClosed
TUES - FRI9:30 a.m. - 4:00 p.m.
SAT9:30 a.m. - 5:00 p.m.
SUN11:30 a.m. - 5:00 p.m.

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