Mini Medical School Boot Camp Application & Permission Form Saturday, April 20, 2024 8:00am – 2:00pm (local time) Huntington Convention Center, Cleveland, Ohio Guidelines:– Parents are responsible to transport their children to the program and back home.– Children must be dropped off and signed in by 7:30am, and be picked up at 2pm (sharp), at the Huntington Convention Center, Cleveland, Ohio at SAGES Meeting.– Lunch will be served.– The program is presented in English and there is no charge for the students to attend.– Upon completion, each student will receive a certificate of participation as well as the possibility of winning special recognition awards. Student/ Parent or Guardian to fill out: School/Student InformationSchool Name:* Student Name:* First Last Student Email Address* Current Grade* 12th (for U.S. students-senior) 11th 10th 9th 8th 7th Current Overall Grade Point* Statement of Interest*State a reason why the student is interested in attending our program. Teacher/Counselor Name* First Last Teacher/Counselor Phone*If knownTeacher/Counselor Email Address* Parent/Guardian/Emergency Contact InformationParent/Guardian Name* First Last Parent/Guardian Phone:*Emergency Contact Name (if different from parent above) First Last Emergency Contact Phone (if different from parent above)I give permission for my child to attend the Mini Medical School Boot Camp*Saturday, April 20, 2024 from 8:00am to 2pm (local time). I agree. Parent/Guardian Email Address (for confirmation/acceptance):* Photo and Video Release Form – Permission to Use Photograph and Video RecordingI grant to SAGES, the right to take video and/or photographs of my child (name specified above) in connection with this event. I authorize SAGES, its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that SAGES may use such videos and/or photographs of the participants with or without their name identification and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content. I have read, understand and agree to the above. Emergency Treatment Consent*In case of an emergency, I give permission for my child to receive medical treatment deemed necessary and appropriate by any physician present, and I accept responsibility for any cost incurred for such treatment. I have read, understand and agree to the above. PhoneThis field is for validation purposes and should be left unchanged.
