PARENT/GUARDIAN INFORMATION: The information listed on this form is correct to the best of my knowledge, and the Participant described herein has permission to engage in all prescribed activities, which may include indoor and outdoor activities, except as noted on this form or in writing. As Parent/Guardian, I authorize Northeast Middle School Summer program personnel to seek emergency treatment as required and to transport my child/children to the appropriate medical treatment facility in the event that urgent emergency care is necessary. AUTHORIZATION TO PARTICIPATE / TREAT: I hereby give my Student permission to participate in all activities scheduled by the Directors and staff of the Summer Program. On behalf of my, my heirs, executors, administrators, and assigns, I/we hereby waive and release any and all rights and claims for damages I/we may have against the Summer Program, Northeast Middle School as well as any other persons connected with the Summer Program, their heirs, executors, administrators, successors and assigns for any and all injuries which the above minor may suffer while taking part in the Summer Program or as a result thereof. I hereby authorize the Directors, staff and Program leaders to attend to minor injuries while acting within the scope of his or her discretion. Additionally, I hereby authorize the Directors, staff and Program Leaders to provide emergency care that includes routine procedures (band-aides, and/ or topical treatments) as necessary to my minor child or dependent. Arrival/Dismissal: I understand that is my responsibility to arrange transportation to and from the Summer Program. I will have my student here by 8:00 AM and picked up no later than 12:05 PM. Any student not picked up by 12:10, will incur a $1 per minute late fee; and must be paid on the next day. Types of payment accepted - checks, cash or money orders. A receipt will be given for cash payments only. The canceled check or Money Order receipt will serve as the receipt for those payments. I have read the above information and have decided that my Student s) may have their pictures taken.PARENT CONSENT FOR RESEARCH: Some administrators will assist with the summer program and may ask your child(ren) their opinions about their interest in subjects in school and potential careers. Moreover, questions may be asked about what the schools could do to enhance their interest. I understand that my Child(ren)'s participation is voluntary. I have read the above information and have decided that my Child(ren) can participate in providing information about school and career interests. If you agree or disagree with the terms above click the box below. *
