Crawford County School-To-Work

Crawford County K-12 Career Education Alliance

Career Camp 2017

Medical Form

I hereby give permission for my child ______, to

(name)

participate in the Crawford County K-12 Career Education Alliance Summer Camp activity on July 11th,12th and 13th, 2017.

Please provide (daytime) phone numbers of three (3) individuals (parents, guardians, or other adults) who may be reached in case of an emergency.

1. ______

Parent/Guardian Name Phone#

2. ______

Parent/Guardian Name Phone#

3. ______

Emergency Contact Name Phone#

Doctor’s Name ______Doctor’s Phone# ______

Any medications needed during camp:

______

(To be clearly labeled and handled in accordance with school policy).

Allergies, health concerns that the Crawford County Career Education Alliance should be aware of:

I hereby relieve the Crawford County Career Education Alliance and the Meadville Chamber of Commerce Foundation of all responsibility beyond that of normal supervision. Consent is also given to transport my child to and from the Career Camp by Crawford County Career Education Alliance staff, Crawford County CTC staff, contracted staff or contracted transportation services and vehicle.

______

Parent/Guardian Signature Date