Summer Permission Form

Summer 2019 Sign Up

State regulations require we have parental contact information and one emergency contact person.
Please print clearly

Program enrolled in (required):

Your Child's Name (required)

Parent/Guardian Name (required):

Child's Date of Birth (required):

Phone (required):

Email (required):

Second phone contact in case of emergency:

MEDICAL
Any legal restrictions on the release of your child or records to a non-custodial parent (required)? YesNo

Any medical restrictions we need to know about? YesNo

Child is allergic to:
EpiPen? YesNo

Does your child have a disability and require accommodations to participate fully in program activities,
Please contact the Disabilities Office at 978-630-9120 to discuss specific needs.

PERMISSIONS I hereby allow MWCC to photograph the child listed above for use in any
type of media MWCC deems appropriate. This can include, but is not limited to, newspaper stories,
printed literature and online information. I hereby give MWCC, its legal representative and assigns,
those for whom MWCC is acting, and those acting with its permissions, or its employees,
the right and permission to copyright and/or use, reuse and/or publish, and republish, photographic pictures.
I hereby allow MWCC to photograph the child listed above (required): YesNo

PERMISSION AND ASSUMPTION OF RISK AND RELEASE
I give my permission for the child listed above to participate in the selected program(s).
I understand that in the unlikely event of an accident, every attempt will be made to contact the person(s)
named on form. If unsuccessful, I give my permission to the staff to secure emergency medical services to
aid my child, including (if necessary) hospitalization. Any expense arising from the injury or illness is the
responsibility of the person signing below. In consideration of being permitted to participate in this program,
I, the undersigned in full recognition and appreciation of the dangers and hazards inherent in such activities,
which are described in this brochure, during my child’s enrollment and/or participation in MWCC activities
during this program, do hereby agree to assume all risks and responsibilities surrounding my participation in
this program, or activities undertaken as an adjunct thereto; and I assume all risks for injuries and illness;
caused by or related to this program; and further I do for myself, my heirs and personal representative hereby
defend hold, harmless, indemnify and release, and forever discharge MWCC and all its officers, agents,
and employees from and against all claims, demands, and actions, or causes of actions, on account of damage
to personal property, or personal injury or death which may result from my participation, and which results from
the causes beyond the control of, and without the fault or negligence of MWCC, its officers, agents or
employees, during the period of participation. I give my permission for the child listed above to participate in the
selected program(s) (required): YesNo

Parent/Guardian Initials (required):

REGISTRATION IS NOT COMPLETE AND YOUR CHILD(REN) CANNOT ATTEND UNTIL THE MEDICAL/PERMISSION FORM IS COMPLETED AND SUBMITTED. Go to this link to download https://mwcc.edu/wp-content/uploads/2019/04/2019-Summer-Medical-Form.pdf

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