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Appendix 6

Society of Hispanic Professional Engineers, Inc.

Advancing Careers in Engineering (ACE) Program

LIABILITY RELEASE, PARENT PERMISSION AND EMERGENCY

CONTACT FORM

I hereby state that I, | | , am the custodial |
| parent/legal guardian (please print) | | |
parent or legal guardian of | | , a minor. I therefore, grant |

student (please print)

permission forthis student to attend/participate in any sponsored field trips or to attend any authorized activities as part of the ACE Program.

I understand that the Society of Hispanic Professional Engineers, Inc. (SHPE) and its affiliated staff will not be liable for any unauthorized leave by the above named student. I further understand that such unauthorized leave will be the responsibility of the studentand the parent or the legal guardian as the signatory below.

I, , release and save harmless SHPE and any and all of

parent/legal guardian (please print)

its employees or volunteers from any and all liability for any and all harm arising to my son/daughter as a result of the field trips and/or activities, and waive any claims against them.

In the event of an emergency and if neitheremergency contact can be reached; I, the undersigned, authorize SHPE to take any emergency medical measures deemed necessary for the care and protection of my child. This includes, if necessary, treatment by a physician, paramedic, and/or transfer to the hospital. I give permission for limited treatment for minor illness and/or injuries. In case of emergency, the student will be referred to thenearest medical facility for care at the expense of the parent or under insurance provided by the student’s insurance.

Students should immediately report any injury or illness symptom to the chaperone or SHPE. Failure to report such a condition would be the sole responsibility of the student, and SHPE would not be held responsible in case the situation worsens.

In case of emergency, pleasecontact the following:

Emergency Contact #1 | | | | Emergency Contact #2 | |
Name | _________ | Name | ________________ | |
Relationship ______________________________________ | Relationship ________________________________ | |
Home Phone (_____) | _________ | | | Home Phone (_____) | _______________ | |
Work Phone (_____) | | | | | Work Phone (_____) | | __________________ || | |
| | | | | | | | | | | | | | |
| | | | | | ________ | | | | | | | | |
Parent/Guardian Signature | | | | Date | | | | |
| | | | | | ___ /____/____ | | | _______________ | | | |
Name of Student (PLEASE PRINT) | | | Date of Birth | Age of Student | |
_______________________________________________________________________ | | || | | |
Name of School | | | | | | | | | | | | |
REVISION 07.1010 | | | | 28 | | | | | | | | |
| | | | | | | | | | | | | | |

Appendix 7 | | | | |
| | Society of Hispanic Professional Engineers, Inc. | |
| | Advancing Careers in Engineering (ACE) Program | |
| | PHOTOGRAPH RELEASE AND CONSENT FORM | |
Name of Student:_________________ | | | |
Age: ___ _ | School: ______________________ | ______________________ | Grade: ____ |
I, | | hereby, give permission to the |
| Parent/legal guardian (please print) | | | |

Society of Hispanic Professional Engineers, Inc. (SHPE) to photograph or video tape my child, ________________________________, only during their participation in the ACE pre-
Student (pleaseprint)

college program. I further give permission to use their photographs and statements featuring their involvement in the ACE pre-college day activities; for SHPE publication purposes during or after this event.

Parent/Guardian Signature Date

Parent/Guardian Telephone:

Parent/Guardian Address:

Please note: When photograph, videos, or quotes are used in SHPE’s publications a...
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