Student Intake
Emergency information and Waiver
Student Name
First Name
Last Name
Phone
*
Student's direct phone number for communication throughout the semester.
Email
*
Student's direct email for communication throughout the semester.
Are you (the student) over 18 years old?
Yes
No
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Emergency Contacts
Emergency Contact #1
*
First Name
Last Name
Contact #1 Mobile Phone
*
Please enter a valid phone number.
Contact #1 Home Phone
Please enter a valid phone number.
Contact #1 Relationship
*
Please Select
Parent
Sibling
Child
Grandparent
Aunt/Uncle
Cousin
Friend
Coworker
Supervisor
Other
Emergency Contact #2
*
First Name
Last Name
Contact #2 Mobile Phone
*
Please enter a valid phone number.
Contact #2 Home Phone
Please enter a valid phone number.
Contact #2 Relationship
*
Please Select
Parent
Sibling
Child
Grandparent
Aunt/Uncle
Cousin
Friend
Coworker
Supervisor
Other
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Medical Information
Do you have any known allergies?
*
Yes
No
Please share any allergies we should be aware of.
*
Do you have any dietary restrictions?
*
Yes
No
Please share any restrictions we should be aware of.
*
Any other medical information we should know in case of emergency?
*
Yes
No
Please explain.
*
Insurance Company
Policy Number
Preferred Hospital
Do you have any physical conditions that would affect your ability to perform any construction activities?
*
Yes
No
Please explain your limitations.
*
*
I certify that all the information provided is correct.
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Waiver of Liability
Legal Guardian Name
*
First Name
Last Name
Legal Guardian Signature
*
Student Name
*
First Name
Last Name
Student Signature
*
Today's Date
*
-
Month
-
Day
Year
Submit
Should be Empty: