SAGES 2023 Mini-Medical School Bootcamp Application & Permission Form

Mini Medical School Boot Camp Application & Permission Form

Saturday, April 1, 2023; 7:30am – 2pm
Convention Center in Montreal, QC

Guidelines: Parents are responsible to transport their children to the program and back home. Children must be dropped off and sign in by 8am, and be picked up at 2pm, at the Convention Center in Montreal, QC - SAGES Meeting. Lunch will be served. The program is presented in English and there is no charge for the students to attend. Upon completion, each student will receive a certificate of participation as well as the possibility of winning special recognition awards.

Student/ Parent or Guardian to fill out:
School/Student Information
School Name:*
Student Name:*
First Last
Student Email Address*
Current Grade*
- 12th (for U.S. students-senior)
- 11th
- 10th
- 9th
- 8th
- 7th
Current Overall Grade (enter %)*
Statement of Interest*
State a reason why the student is interested in attending our program.
Teacher/Counselor Name*
First Last
Teacher/Counselor Phone
If known
Parent/Guardian/Emergency Contact Information
Parent/Guardian Name*
First Last
Parent/Guardian Phone:*
Emergency Contact Name (if different from parent above)
First Last
Emergency Contact Phone (if different from parent above)
I give permission for my child to attend the Mini Medical School Boot Camp*
Saturday, April 1, 2023 from 7:30am to 2pm.
- I agree.
Parent/Guardian Email Address (for confirmation/acceptance):*
Photo and Video Release Form - Permission to Use Photograph and Video Recording
I grant to SAGES, the right to take video and/or photographs of my child (name specified above) in connection with this event. I authorize SAGES, its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that SAGES may use such videos and/or photographs of the participants with or without their name identification and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.
- I have read, understand and agree to the above.
Emergency Treatment Consent*
In case of an emergency, I give permission for my child to receive medical treatment deemed necessary and appropriate by any physician present, and I accept responsibility for any cost incurred for such treatment.
- I have read, understand and agree to the above.
Name
This field is for validation purposes and should be left unchanged.

Mini Medical School Boot Camp Application & Permission Form

Student/ Parent or Guardian to fill out:

School/Student Information

Parent/Guardian/Emergency Contact Information

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