Registration and Permission Form

Registration & Parental Consent Form
January 13-15, 2007

Registration deadline January 9, 2007
Fax: (301) 583-1986
Email: CSHawkins@co.pg.md.us
Please
Name:_______________________________________________________________________________
First Middle initial Last

Mailing Address:_______________________________________________________________________
City State Zip

Home Phone:_____________________ Email Address:_____________________________________

Birth date:_______/_____/_______ Male_____Female____ Ethnicity (optional)_________________
Month Day Year

School:______________________________________ Grade_______ Do you drive?____________


Emergency Contact Phone Information
Name of Parent/Guardian ______________________________________________________________

h ________________ w __________________ c _______________

If I am not available, the following individual may be contacted in an emergency:

Name_______________________________________________ Relationship ___________________

h ________________ w ___________________ c ________________


Permission
I give my permission for my child ___________________ to participate in Prince George’s Office of Emergency Management Teen CERT Training.

I understand that reasonable measures will be taken to safeguard the health and safety of my child. I understand that I will be notified as soon as possible in case of an emergency. In the event of an accident or illness, I authorize medical care as deemed necessary for the welfare of my child. Every effort will be made to contact parents/guardians immediately if necessary.

I also give permission to Prince George’s County Office of Emergency Management and Prince George’s Volunteer Center to use any and all photographs, and/or videos/audios of my child obtained while participating in the Teen CERT training to promote emergency preparedness and volunteerism.

Following completion of this training, youth will have the opportunity to participate in many individual and group volunteer projects. By signing this application, I (parent/guardian, if member is under 18) grant permission for participation in those events without requiring additional permission forms.


______________________________________ _______________________________________
Youth’s Signature Date Parent/Guardian’s Signature Date