West Scranton High School Surgery Live 3.25.26

Surgery Live! Permission Slip

Event: February 11th 9 am to 11:30 am (approximately)
Location: WSHS Auditorium

This is a live surgery at UPMC

Surgery: Watchman Heart Surgery

Questions?

Email Frannie@eocinc.org

Text: 570-401-1173

or Miss Miller in Guidance
Student Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Email (personal not school)
example@example.com
Student Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Student Birthdate:*
Gender
Race

American Indian/Alaska NativeAsianBlack/African AmericanWhiteNative Hawaiian/Pacific IslanderTwo or more races
I am:*
Grade: *
I am taking Dual Enrollment Classes:*
Educational Opportunity Centers, Inc. is a non-profit educational organization that manages the TRIO Talent Search Program and EOC Program. I understand that the Surgery Live! Virtual field trip is optional for expanding knowledge and experiences and I freely choose to participate in this class and the Virtual Field Trip as described in the flyer. I understand that this virtual Trip will include a Live Surgery-Watchman Heart performed at UPMC and includes Question & Answer session with the Surgical Team. Please add any questions below:
Questions can be answered during the surgery.
Student Answer: I am possibly interested in a career in a health field:*

NursingPhysicianTherapyAdministrativeUndecidedOther
Student Answer: I know what type college that I would like to attend:*

Community CollegePennsylvania State CollegePrivate CollegeI have no idea
Student Signature: I agree to be respectful during the presentation. I understand that the fee for this Virtual Field Trip is covered by the EOC, Inc TRIO Program and I will be respectful during this very sensitive event.*
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Email address
example@example.com
Parent Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Highest parent education completed:*
Household Income:
Family income is:

Above the income for my household sizeBelow the income for my household sizeUnsure, need help deciding
I give permission for my child to participate in the Virtual Field Trip to observe a Live Surgery performed at UPMC. *
Should be Empty:

Surgery Live! Permission Slip