NBT Emergency Contact Information

Type Name/Signature of Parent/Guardian

Last Name

First Name

Gender

Male

Female

Date of Birth

Grade in Fall 24

Parent/Guardian email address

Address

City

State

Zip

Home Phone

PLEASE LIST A PHONE NUMBER WHERE CARE GIVER WILL RESPOND:

Father/Guardian Name

Primary #

Alternate #

Mother/Guardian Name

Primary #

Alternate #

In the event of accident or illness, I do hereby consent to whatever x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care considered necessary in the best judgment of the attending physician, surgeon, or dentist and performed under the supervision of a member of the medical staff of the hospital or facility furnishing medical or dental services. Further, I agree that the District and its personnel are not legally or financially responsible or liable for any claim arising from any consent given in good faith in connection with diagnosis or advised treatment.

1) EMERGENCY CONTACT (Other Than Parents) - I AUTHORIZE THESE ADDITIONAL PERSONS TO PICK UP MY CHILD (IN-PERSON CAMPS ONLY):

Name

Relationship

Phone

Name

Relationship

Phone

Name

Relationship

Phone

2) MEDICAL INFORMATION:

Does student take medications?

Yes

Note: Any medication dispensed to your child must be brought to camp in its original prescription container and include written directions from child’s physician.

Name of Medication

Amount

Frequency

I give consent for my child to self-administer his/her own medications as listed above while my child participates in the Santa Clarita Community College District Community Education Summer Institute Program.

Please list any allergies (medication, food, other) and/or medical conditions we should be aware of

3) PHOTOGRAPH RELEASE: I irrevocably consent to and authorize the use and reproduction by District Community Education(CE), or anyone authorized by CE, of any and all photographs and video which you have taken of my son or daughter during the timethey are registered for the COC Summer Institute. CE may use the photographs, film, video, negatives, or proofs for marketing theCOC Summer Institute in printed publications including the COC Summer Institute website. Additionally, I waive any right toroyalties or other compensation arising or related to the use of the photograph or video. All negatives and positives, together with theprints shall constitute the property of CE, solely and completely.

Choose One

Yes I agree

No I do not agree

Note: Any medication dispensed to your child must be brought to camp in its original prescription container and include written directions from child’s physician.

Parent/Guardian/Signature