NORTHERN TIER INDUSTRY& EDUCATION CONSORTIUM

SUMMER HEALTHCARE PROGRAM PERMISSION FORM (Please print clearly) I, the parent or guardian of ____________________________, give permission for the named participant to receive emergency medical treatment if necessary. I understand that every attempt will be made to contact me, or the emergency contact named attached, before taking this action. I will be financially responsible for any medical attention needed during camp or resulting from an injury received while participating in camp activities. My medical insurance shall be the insurance coverage for any and all medical treatment. I further understand that NTIEC retains the right to use for publicity and advertising purposes any electronic media taken during camp activities. Signature: Printed Name:

Date: _____________

Please return this form and make check payable for $50.00 to the following address by July 3, 2017 NTIEC PO Box 200 Dimock, PA 18816

P.O. Box 200, Dimock, PA 18816 Phone (570) 278-5038, Fax (570) 278-2731