MSU Parent-Guardian-Consent form

MICHIGAN STATE UNIVERSITY PARENT/ GUARDIAN CONSENT FORM IN-PERSON AND REMOTE/ HYBRID YOUTH PROGRAMS

I grant permission for (print participant's name) participate in all educational and social activities of the following MSU program or activity:

Program name

Program dates

Date

MSU unit/department

Risk of exposure to COVID-19 is inherent in any public place where people gather.I understand that my child must follow all University guidelines for COVID-19 safety while participating in this program. I understand that in-person program sessions may entail field trips and/or campus facility tours. I also understand that participants may engage in athletic or other recreational activities that have special risks. Iunderstand that sessions may entail the use of various remote/ online platforms or software programs. I also understand that participants may engage in digital communication.

I have read the session descriptions and approve of my child's selections, and I accept the risks associated with my child's participation.

Iunderstand that my child has a role to play in regard to his or her safety and security.I will speak with my child about the need to honor rules and to behave responsibly. (Please print):

Parent or legal guardian

Signature

Date

Parent or legal guardian

Signature

Date

Program

Dates Attending

Date

MEDICAL TREATMENT AUTHORIZATION FOR MICHIGAN STATE UNIVERSITY

Your child will be involved in a Michigan State University program on the above date(s This form must be completed and signed by a parent or guardian to give a medical facility permission to treat the participant for minor injuries or medical problems. In the event of serious injury or illness, the parent or person designated will be contacted. Treatment will proceed before contacting the parent or person designated only if the situation is urgent and does not permit delay.

Participant's full legal name:

Last

First

MI

Birth date

Date

Primary care physicians name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Physician's phone

Physicians address

Policy holders name and relationship to participant

Policy holders address

Please attach a photocopy of both sides of your insurance card OR complete the information requested below.

Insurance company name and address

Insurance company phone number: ()

All policy numbers (please identify):

If you have HMO insurance, please list the emergency treatment authorization phone number: ()

Employers name and address

INFORMATION NEEDED ABOUT PARTICIPANT: Please check yes or no. If yes, explain below or on another sheet if you need more room.

Does the participant have any chronic health problem or illness?

Does he or she have any acute illness now?

Has the person been treated recently for some medical problem?

Does he or she have any allergies?

Does he or she have any allergies to medication or local anesthetics?

Date of his or her last tetanus shot

List any medications he or she is now taking for treatment of any medical problem.

Please place yes or no here to the questions about

Date of his or her last tetanus shot

Date

OFFICIAL AUTHORIZATION FOLLOWS:

I parent or legal guardian recognize that while attending this program medical treatment on an emergency basis may be necessary for my child and I further recognize that the program director may be unable to contact me for my consent for emergency medical care I do hereby consent in advance to such emergency care including hospital care as may be deemed necessary under the circumstances and to assume the expenses of such care I also authorize the medical facility to release any and all information required to complete insurance claims and also authorize insurance payment directly to the medical facility

Signature of ParentGuardian or of participant aged 18 and up

Date

MICHIGAN STATE UNIVERSITY MEDIA RELEASE FORM

Participants in MSU-sponsored programs and activities may be photographed and videotaped for use in MSU promotional and educational materials. The participants are not identified by name in the materials. I authorize MSU to record the image and voice of the subject named below and I give MSU, and all those acting with MSU's approval, all rights to use these images and voice recordings. I understand that such images and/or recordings may be used for educational and promotional purposes. This authority extends to all conventional and electronic media, including the Internet and any future media, and to any printed material. I understand and agree that these images and recordings may be duplicated, distributed with or without charge, and/or altered in any manner without compensation or liability, in perpetuity.

Print subjects name

Signature of Parent/Guardian of minor participant or of participant aged 18 and up:

Date

Email

example@example.com

Signature

Date