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PROGRAM INFORMATION FORM
Student
Responsibility in Participation-
Course or Activity: Project Explore Date:
Instructor (s)______________________________ Period of Time_______________________
______________________________ _______________________
By signing below I acknowledge that I have thoroughly read and understand the statements made below and recognize my responsibility in their regard.
1. As a participant in intramural, intercollegiate, or other types of athletics, and/or field trips, practices, or work experiences, the students must understand that the University does not provide any health/accident insurance on his/her behalf.
2. It is each student’s responsibility to adhere to all instructions given by the University instructor or employee in charge, and to follow the policies and procedures for any official activity in which the student is involved.
__________________________________________ ________________________
Signature of Parent or Guardian Date
Photo Release Form for Minor
I
hereby affirm that I am the parent or guardian of ___________________________
and without further consideration I hereby irrevocably consent that any
photograph (s) which may be taken of him or her by representatives of the
__________________________________________ ________________________
Signature Date
EMERGENCY MEDICAL FORM
Name_____________________________________________________________
Address__________________________________________________________
City/State/Zip___________________________________________________
Home Telephone________________Parent's
Work Phone________________
Cell Phone ________________
Person to be called in event parent or guardian cannot be reached in an emergency:
Name_________________________________Relationship________________
Address__________________________________________________________
City/State/Zip___________________________________________________
Home Telephone__________________Work Telephone___________________
Special medical conditions such as physical restrictions, allergies, emotional considerations, or other relevant data of which program personnel should be aware:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Date of last tetanus shot__________________
Doctor's Name____________________________Telephone_______________
This is to authorize treatment and, if necessary, the use of anesthesia if unable to contact parent or guardian for the above student.
______________________________________ ____________________
Signature of Parent or Guardian Date