2012 KIDS & TEEN COLLEGE


REGISTRATION FORM PAGE 2 REGISTRATION INFORMATION - Continued


STUDENT’S NAME


Emergency Contact Information (Please list contact numbers at which contact can be reached during the program) #1 Emergency Contact Name


#1 Emergency Contact Phone #2 Emergency Contact Name #3 Emergency Contact Name #2 Emergency Contact Phone #3 Emergency Contact Phone Relationship to Student Relationship to Student Relationship to Student


Drop Off and Pick-Up Information (Please list all individuals authorized to pick-up minor from the program. Minors will not be released to anyone not designated by parent/guardian) #1 Name


#1 Phone #2 Name #2 Phone Relationship to Student Relationship to Student


Medical Information HEALTH INFORMATION Please describe any medical condition (including allergies, recurring illness, disabilities, etc.) [


] NONE


Please list all medications taken regularly and/or that your child will be bringing with them.** [ ] NONE


Please describe any Special issues that the program directors and instructors should be aware of (diet restrictions, learning challenges, behavioral challenges, etc.).*** [ ] NONE


** Note: Penn State program officials will not dispense over-the-counter or prescription medications to participants. Participants will be allowed to possess and take medications on their own if permission is granted in writing by the parent/guardian. Medications must be in their original containers and listed on this form. ***Note: Penn State encourages qualified individuals with disabilities to participate in its programs and activities. Information involving special accommodations must be received by our office in writing at least 1 month prior to the start of the program for which you are registering your child. This information will be kept confidential and revealed only to the necessary staff and health professionals.


Medical Treatment Authorization In the event that I am unavailable for purposes of providing parental/guardian consent, I hereby authorize emergency medical treatment as deemed necessary for my child. I understand that the consent and authorization herein granted does not include major surgical procedures and is valid only during the course of the program.


Family Physician ________________________________________ Phone #______________________________________ Medical Insurance Company: _______________________________________ Policy #_______________________________ Parent/Guardian signature__________________________________________________ Date___________________________


I/we give my/our permission for you to release, to the appropriate medical care provider(s), any records necessary for treatment, referral, billing, or insurance purposes. (Please check one) _______ Yes


_______ No


HIPAA Penn State honors the privacy of the participants in its programs and complies with the national regulations regarding health information. For a summary of the national standard, see www.hhs.gov/ocr/privacy/index.html


Federal law requires that institutions of higher education gather the following information regarding ethnicity and race.


Please check () the appropriate responses: Is the student’s ethnicity Hispanic/Latino (Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish Culture or origin)?  Yes, Hispanic/Latino  No, Not Hispanic/Latino


What is the student’s race? (Select one or more.)  White  Black or African American  Asian  American Indian or Alaska Native  Native Hawaiian/Other Pacific Islander


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