Chamberlain Medic Camp - PHOTO and PROGRAM PERMISSION FORM

Chamberlain Medic Camp - PHOTO & PROGRAM PERMISSION FORM

Thank you for allowing your student to participate in Medic Camp! We are excited to provide students with hands-on experiences in Emergency Medical Services careers. To ensure we can capture and share the impact of this program, we request your permissionfor photography and student information as outlined below.
Please select the session you are registering for:

Session 1 (9:00 AM - 10:15 AM)Session 2 (10:30 AM - 12:00 PM)
Student Information
Student Name

First NameLast Name
Date of Birth

MonthDayYear
Date
School student is currently attending
Student's Grade
Parent/Guardian Name

First NameLast Name
Parent/Guardian Email
example@example.com
Parent/Guardian Phone Number
Please enter a valid phone number.
Would like to receive information about any health career camps and opportunities for my student.

Yes, sign me up for emailsNo, thank you
SECTION 1: PHOTO & MEDIA PERMISSION
I, the undersigned, hereby grant the Northeast South Dakota AHEC, its partners, and approved speakers and representatives’ permission to take photographs, video recordings, and other media of my child during Medic Camp. I understand that these materials may be used for educational, promotional, and outreach purposes, including but not limited to:
- Program reports and presentations
- Promotional materials (brochures, flyers, etc.)
- AHEC’s website and social media platforms
- Newsletters and media releases
I acknowledge that neither I nor my child will receive compensation for the use of these images and that all rights to the images will be retained by AHEC and its representatives.
YES, I give permission for my child to be photographed/video recorded for thepurposes stated above.NO, I do not give permission for my child to be photographed/video recorded.
SECTION 2: PROGRAM EXPERIENCE & FEEDBACK CONSENT
To help us evaluate and improve Medic Camp, we collect limited information about student participation, interests, and feedback. This helps us understand what students enjoy most and how to make future camps even better.
- Information may include attendance, surveys, and general feedback.
- All collected data will remain confidential and used only by SD AHEC and affiliated reporting organizations.
- No personally identifiable information will be published or shared publicly.
YES, I give permission for my child’s participation information to be used for internal program evaluation.NO, I do not give permission for my child’s participation information to be used for internal program evaluation.
Parent/Guardian Signature

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For any questions regarding this form, please contact Mikayla Titus, Executive Director of Northeast SD AHEC, at 605.715.5152 or m.titus@nesdahec.org . Thank you for your support in making Camp Med a meaningful and memorable experience!
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Chamberlain Medic Camp - PHOTO & PROGRAM PERMISSION FORM

Student Information

SECTION 1: PHOTO & MEDIA PERMISSION

SECTION 2: PROGRAM EXPERIENCE & FEEDBACK CONSENT