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Staten Island Children's Museum
Expanding Minds and Imaginations Since 1974
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Visit
Guidelines for Visiting
Accessibility
Exhibits
Birthday Parties
2023 Summer Mini Camps
Day Camps for School Breaks
Tot’s Time
Weekend Wonders
Nearby Attractions
For Teachers
Field Trips
Rent the Museum
In School Programs
Supplemental Resources
Community Gallery
Join + Give
Make A Donation
Become A Member
Corporate Giving
Internship and Volunteer Opportunities
Employment Opportunities
Community
At Home with SICM
About Us
DEI Values and Plan
Staff and Board Listings
Financials
Donations for Schools
SICM at Community Events
STEAM on the Go
SICM in the News
SICM in Schools
Summer Camp Registration Form
Please enable JavaScript in your browser to complete this form.
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Step
1
of 2
Participant Information
Camper's Name
*
First
Last
Participant's Age
*
Contact Information
Name of Parent/Guardian
*
First
Last
Email
*
Phone (home/cell/work)
*
Address
*
Address Line 1
Address Line 2
City
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District of Columbia
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New York
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Ohio
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Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Are you a SICM member?
*
Yes
No
Expiration Date
Emergency Contact Name
*
First
Last
Relationship to Participant
*
Emergency Phone (home/cell/work)
*
In the event of an emergency, SICM will call 911 and your child will be placed in the care of an EMT.
Other than you, who is authorized to pick up your child?
*
First
Last
Identification Required
Relationship to Child
*
Health History
To be answered for each registered participant. Please note that we are not allowed to administer medication to the participants.
Does your child take any medications* or receive any services inside or outside of school? If yes, please specify:
List any allergies and known reactions:
*Please note we are not allowed to administer medication to the participants.
Is your child up to date on all well-care visits and vaccines?
*
Yes
No
Does your child have any physical limitations that require any accommodations? If yes, please specify:
Is there anything else you would like us to know about your child?
Permissions
Please check each box as a form of agreement:
*
I understand that disruptive behavior will not be tolerated. It will be addressed and should it persist, SICM reserves the right to cancel that participant’s registration without a refund.
I understand that my child will not be permitted to participate if they have a temperature above 99 degrees or are exhibiting other signs of illness.
I understand my child must wear a mask at all times and follow instructions for social distancing.
I understand that my child must be 4 years old by the first day of the program and must be able to use the bathroom independently.
I understand that there will be no refunds given for missed classes for any reason.
I certify that the Health History above is correct and all relevant information has been included to best of my knowledge.
Next
Program Waiver and Release of Liability Agreement
Name of Camper (hereinafter, "my CHILD")
*
First
Last
Terms and Conditions
*
I have read and agree to the terms and conditions below
I, the parent or guardian of my CHILD give permission for my CHILD to attend the Staten Island Children’s Museum (hereinafter, SICM) Summer Camp program. The program activities may include but not be limited to running/ walking/ hiking, dance, theater games, art, science activities, playing outside, and gardening.
Medical Treatment
If my CHILD is injured and requires medical attention, I give consent and authority to SICM to obtain emergency medical treatment on my CHILD’s behalf and do hereby release and forever discharge SICM from any claim whatsoever which arises or may hereafter arise on account of any first aid, treatment, or service rendered in connection with the SICM camp activities.
Liability
I hereby release the SICM from any and all claims which I or my CHILD may have against the Program arising from, resulting from or in connection with the camp; including but without limitation, any claims, demands or causes of action for injuries to my CHILD, including but not limited to injuries resulting from the negligence of SICM. I understand SICM is not responsible for theft, loss or damage of personal property. The agreement is signed for the purpose of fully and completely releasing, discharging, and indemnifying SICM from all liability as herein described.
Photograph and Interview Release
In exchange for the opportunity for my CHILD to participate in the SICM Summer Camp program, I irrevocably authorize SICM and its affiliate, licensees, assignees, and successors to photograph or interview my CHILD and to use such photographs or interviews, as well as the name of my child in any of its promotional materials, including its brochures, advertisements, newspapers, web sites, videos, or other materials in print, audio, electronic or visual media. In addition, I voluntarily waive any right, cause of action or demand, of any kin whatsoever resulting from SICM’s photograph or interview of my CHILD from which any liability may or could accrue to SICM. I also understand that SICM will not give me or my CHILD any compensation for using my CHILD’s photograph or interview in its promotional materials. Thus, by signing this document, I waive any rights to any compensation now or in the future. I understand that this document includes the entire agreement and understanding between me and SICM with respect to the release of photographs or interviews of my CHILD.
Parent or Legal Guardian Name
*
First
Last
Parent or Legal Guardian Signature
*
Clear Signature
Please use your mouse to sign your name above.
Today's Date
*
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Submit
To see full page and print a copy of the Waiver and Release of Liability Agreement.
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