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COUNTY ____________________________PENNSYLVANIA STATE ENVIROTHONSTUDENT MEDICAL INFORMATION(Please Type or Print Clearly)Each student participating in the Pennsylvania State Envirothon is required to complete in full the following information:Name of Student: Home Address: Parent/Guardian Name(s): In case of emergency, we must be able to contact you. Please list a day/evening telephone number where you can be reached.Father/Guardian- Day: ( ) Evening: ()Mother/Guardian-Day: ( ) Evening: ( )Other emergency contact person:Name: Relationship: (grandparent, neighbor, etc.)Telephone: ( ) Day/Evening: ( )Health/Accident Insurance Company: Policy Number: Policy Holder: Name of advisor accompanying student: Known allergies: (foods, drugs, insects, etc.)Special medical concerns, NEEDS*, or conditions we should know about: (epilepsy, asthma, diabetes, injuries to bones/joints, etc.)Medications currently taking: (dose and frequency)Date of last tetanus boosterFamily Physician: Telephone: ( )PARENTAL CONSENT STATEMENTI, the undersigned parent/guardian of, hereby give permission to physicians and attendant staff to perform emergency first aid for him/her as they deem necessary, and refer him/her to an off-site physician when deemed appropriate. It is understood that I will be contacted in case of an emergency. It is understood that the Pennsylvania Envirothon Board of Directors will exercise reasonable caution in conducting or participating in the event and I/we agree that they will not be held liable for any accident that may occur.Signature of Parent/GuardianDate* The Americans with Disabilities Act applies to the Pennsylvania State Envirothon and its programs, services, activities, and facilities. If you have any special needs, please contact the Pennsylvania State Envirothon at our mailing address -- 702 West Pitt Street, Suite 3, Bedford, PA 15522 -- or at our email address -- paenvirothon@.Turn over to complete Photo Release form.COUNTY ____________________PENNSYLVANIA STATE ENVIROTHONPHOTO RELEASE(Please Type or Print Clearly)Name: _______________________________________________Address: _____________________________________________ _____________________________________________Parent/Guardian Name: _________________________________(if minor)I hereby grant my consent for use of my/my child’s name, voice, photograph, image and/or likeness, by the Pennsylvania State Envirothon Board or an agency it designates for unlimited broadcast, re-broadcast, print and other reproduction for any media use related to the promotion of the Envirothon program.I further release the Pennsylvania State Envirothon Board or any media agency it designates from any responsibility for remuneration or consideration.___________________________(Signature)___________________________(Parent/Guardian Signature) - if minor___________________________(Date)Turn over to complete Medical Information form. ................
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