2004 Forestry & Natural Resource Careers Week

Medical History & Release

ARE THERE ANY MEDICAL IMPAIRMENTS OR CONDITIONS THE STAFF NEEDS TO BE AWARE OF?____________________________________________

______________________________________________________________________

IS YOUR CHILD ON ANY PRESCRIPTION MEDICATION? NO___ Yes____

IF YES, PLEASE SPECIFY_________________________________________

DOES YOUR CHILD REQUIRE A SPECIAL DIET? NO___ YES___

IS YOUR CHILD A VEGETARIAN? NO___ YES___

DOES YOUR CHILD HAVE ALLERGIES? NO___ YES___

FOODS___ ASTHMA___ HAY FEVER___ POSION IVY___ BEE STINGS___

OTHER___ PLEASE EXPLAIN _____________________________________

IS YOUR CHILD COVERED BY MEDICAL INSURANCE? NO___ YES___

IF YES, PLEASE ATTACH A COPY OF MEDICAL INSURANCE CARD.

STATEMENT OF PERMISSION AND EMERGENCY CARE

My son/daughter has permission to participate in the Forestry & Natural Resource Careers Week. In case of emergency, while attending the program, there may be occasions where immediate first aid may be necessary. I give my permission for my child to be cared for, in this manner, if needed. I give the Garrett Memorial Hospital permission to treat this minor child if emergency circumstances require it.

__________ ___________________________________

DATE SIGNATURE OF PARENT/GUARDIAN

I give any hospital permission to treat this minor child if necessary emergency circumstances require it.

__________ __________________________________

DATE SIGNATURE OF PARENT/GUARDIAN

This program carries a comprehensive insurance policy and is jointly sponsored by the

Maryland Association of Forest Conservancy District Boards and the State of Maryland.

PHOTO DISCLAIMER

I, __________________________________ as parent/guardian of ______________________________

grant ___ do not grant ___ my permission to use photos of my child in promotions for Forestry & Natural Resources Careers Week.

_______ __________________________________

DATE SIGNATURE OF PARENT/GUARDIAN