Family Doctor:
Family Dentist:
Preferred Hospital:
MCCTC
Summer
Camp
EMERGENCY MEDICAL AUTHORIZATION GRANT CONSENT
In a medical emergency, the Parent/Guardian will be notified.
Phone:
Phone:
Phone:
If a specific hospital is designated other than ones seviced by the local emergency service unit, the
Parent/Guardian will accept financial responsibility. Facts concerning the child’s medical history,
including allergies, medications being taken and any physical impairments to which a physician
should be alerted:
Parent/Gaurdian:
Emergency Phone:
If the Parent/Guardian cannot be reached, contact:
Name:
Phone:
Relationship:
In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for
emergency mediacal care at the discretion of MCCTC.
Signature of Parent/Guardian:
Date:
AT&T
MCCTC
Summer
Camp
75%
I do NOT give my consent for emergency medical treatment of my child. In the event of illness or
injury requiring emergency treatment, I wish the school authorities to take the following action:
Signature of Parent/Guardian:
BFF 10:23 PM
Date:
For?:
Students in 6th through 8th grade
WAIVER AND RELEASE OF LIABILITY
Whereas, the undersigned voluntarily desires to participate in the MCCTC Summer Camp being
offered at MCCTC, 7300 N. Palmyra Rd., Canfield, OH 44406, from June 15 through June 17, 2015.
Wheres, the undersigned is aware that there are risks and hazards which may arise through
participation is said activity and the participation in said activity has serious risks, including loss of
life and/or limb and/or property at MCCTC.
Whereas, the undersigned is aware that the camps begin at 8:00 a.m. and conclude at 2:00 p.m., that
30
30
participate in said activity and receive educational and other benefits therefore; the undersigned
hereby voluntarily assumes all risks of accident or personal damage to his/her property, and hereby
releases MCCTC, its agents and employees, from claim liability or demand of any kind sustained,
understands the conditions herein provided. I represent that I have legal capacity and authority to
act for and on behalf of the minor named herein.
Student’s Name:
Parent’s Name:
Signature:
Date:
MCCTC
7300 N. Palmyra Road
Canfield, OH 44406
shall be binding upon any heirs, administrators, executors and assigns of the undersigned.
When?:
June 15th-17th, 2015
@ 8:00 am-2:00 pm
Where?:
MCCTC
7300 N. Palmyra Road
Canfield, Ohio
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Cosmetology
»Learn about proper care of hair, skin,
and nails
»Shampoo and conditioning
»Brushing and thermal care
»Proper nutrition
»Make-up application: Age appropriate
»Nail care
»Filing properly
»Hand care polish application
Mahoning County Career and Technical Center
Summer Career Camp 2015 Registration Form
Medical Occupations
»Learn to take temperature, pulse,
respirations, and BP
»Perform basic first aid and conscious
victim choking maneuver
»Assemble your own first aid kit
»Study basic anatomy
»Practice good nutrition and other
healthcare skills
Summer Camp: June 15-17, 2015 at the MCCTC
Time: 8:00 A.M.-2:00 P.M.
• Early• Childhood
Education• •Exercise
Exercise
Science
Cullinary
Culinary
Medical Occupation
Science
Engineering
• Cosmetology
• Forensics
Engineering
• Cosmetology
• Welding
I.T.
1st Choice
2nd Choice
Student Information
Last Name:
First Name:
Address:
City:
Culinary
»Basic cooking and baking skills
»Mediterranean and American cuisine
»Homemade pizza
»Breakfast foods
Exercise Science
»Learn about exercise programming,
injury recognition, prevention, and
safety
»Crossfit/Jump stretch
»Obstacle course run/recreational
fitness
Zip:
Telephone:
Email:
Name of School:
Current Grade:
Age:
T-Shirt size (adult sizes -- if size not selected, large will be given)
Small
Medium
Large
X-Large
Special Consideration
My child requires the following special consideration:
My child does not require any special consideration.
Engineering
»Mechanical and civil engineering
»Building circuits
»Robotics
»3-D Modeling and printing
»Aerospace
Welding
»Basic shop safety
»Basic oxyfuel set-up
»Safety on oxyfuel set-up
»Flame adjustment
»Cutting mild steel
Verification and Release Statement
In signing this form, I verify that to the best of my knowledge, all information
provided is true, accurate and complete. I understand that miscoduct by my
child will not be tolerated and will result in my child being sent home. I
represent that I have legal capacity to act for and on behalf of the minor
named herein. I understand that I must provide transportation for my child
to and from MCCTC.
Parent/Gaurdian Signature:
Student Signature:
Registration deadline: May 29, 2015
Complete and Return to:
MCCTC
Make checks payable to MCCTC
I am including the following fee(s):
Camp Registration: $25.00
Total Enclosed: