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 slide to unlock 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:
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