Rooted Student Application

 

An asterisk (*) appears next to all required fields.

  • MM slash DD slash YYYY
  • Medical Information:

    The intent is to provide our staff & volunteers with necessary information needed to give appropriate care in case of an emergency. Should any information change on this form, please advise CVCCS immediately.
  • If none put NONE.
  • If none put NONE.
  • I hereby give permission to the medical personnel selected to order X-rays, routine tests, or treatment; to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for my student. In the event I cannot be reached in an emergency, I hereby give permission to the attending physician to administer treatment, including hospitalization, for the person named above. This completed form may be photocopied for trips where participants are off-site.
  • This field is for validation purposes and should be left unchanged.