CHARGE- High School Programming Parent/Guardian Consent Form

As a parent or legal guardian, I give consent for enter child's name here* to participate in the CHARGE- High School Programming and to abide by its rules and regulations. I understand that my child will be expected to adhere to all program requirements and expectations or my child will face removal from the program. I also give my consent to release school records to those involved in the overall selection process of CHARGE-High School Programming and to those administering, mentoring, and counseling in the program. I understand that my child may be photographed or videotaped throughout the program and I approve of my child being in the photographs and/or video free of compensation. I also understand that travel is required during the program and if I am not able to provide transportation for my child to and from the required events I will either allow them to drive themselves if they are of legal age and of valid driving license or commit to finding them a suitable chaperone to transport them. These events include but are not limited to the in-person student workshops at the Center for Health, Education and Research, the monthly/quarterly activity meetings and/or mentoring/shadowing sessions that will be conducted locally throughout the program rotation. I understand that the Northeast AHEC or any other individual associated with the CHARGE-High School Programming will not be providing the transportation or be responsible for scheduling transportation for my child. Opportunely, A REIMBURSEMENT OF $0.50 PER MILE WILL BE PROVIDED as a stipend for travel that is required that has been previously reviewed and approved by the Northeast AHEC.

NOTICE OF NONDISCRIMINATORY POLICY

CHARGE- High School Programming is committed to providing students throughout the Northeast AHEC service region equal opportunities to achieve their future healthcare career goals. CHARGE- High School Programming admits students of any race, color, national and ethnic origin to all the rights, privileges, and activities generally accorded or made available to students while participating in the program. CHARGE- High School Programming does not discriminate on the basis of race, color, physical capabilities, national and ethnic origin in administration of its educational or admission policies.

By signing my signature below, I hereby certify that I have reviewed the information above with my child and it is true and accurate to the best of my knowledge. I agree to all terms and conditions of the CHARGE- High School Programming as stated above.

Name*

First NameLast Name

Date*

Date

Signature*

Thank you for your interest in the CHARGE- High School Programming. For any questions, comments, or concerns, please contact Lakyn Newcomb, CHARGE Program Coordinator at 606-783-6787 or via email at Lakyn.Newcomb@st-claire.org