EMERGENCY MEDICAL FO RM
MVCTC
I HEREB Y GIV E MY CON SENT TO CALL
THE FOLLOWING MEDIC AL CARE
PROVIDER S:
CAREER CAMP
DOCTOR: ____________________ __________________
JUNE 10 - 14, 2013
PHONE:______________ ____________________ ______
DENTIST: ____________________ __________________
9 A.M. – 11:30 A.M.
PHONE____________________ ____________________
MEDICAL SPECIALIST: ____________________ _______
PHONE: ____________________ ___________________
PREFERRED HOSPITAL: ____________________ _____
In the event reasonable attempts to contact me have been unsuccessful, I
hereby give my consent for the administration of any treatment deemed
necessary by the above-named doctor, or in the event the designated
preferred practitioner is not available, by another licensed physician or dentist
and the transfer of the child to any hospital reasonably accessible.
This authorization does not cover major surgery unless the medical opinions
of two other licensed physicians or dentists, concurring the necessity for such
surgery, are obtained prior to the performance of such surgery. Please list
any medications being taken and any physical impairment to which a
physician and the school should be made aware.
www.mvctc.com
For more information:
Mrs. Rhonda Green
Miami Valley CTC
6800 Hoke Road
Clayton, OH 45315
Phone 937.854.6067
rgreen@mvctc.com
Fax 937.837.1594
The Miami Valley Career Technology Center is dedicated to
providing equal educational opportunities and equal
employment opportunities without regard to race, religion,
color, national origin, ancestry, age, sex, sexual orientation,
handicap, marital status, or veteran status.
Is your child allergic to bee stings? Yes_____________ No_____________
Parent/Guardian Signature:__________________________
Date: __________________________________________
For students who will be
entering the
th
th
8 , 9 , and 10th grades
Date of publication
Join the fun while you
learn at this FREE
Career Exploration
Opportunity
WHAT IS
CAREER CAMP?
CAREER CAMP
APPLICATION
Name ___________________________________
Full Address
__________________________________________
__________________________________________
__________________________________________
Phone ___________________________________
Career Camp is a FREE one-week
exploration program designed to give
students entering eighth, ninth, and tenth
grades a hands-on experience in various
careers to help them make good career
decisions. For nearly 20 years, students
from our partner schools have been
attending the MVCTC Career Camp.
This year’s camp will be held at the MVCTC
campus the week of June 10-14, 2013. The
camp runs from 9 am until 11:30 am each
day.
Friday, June 14, parents are invited to a
pizza party lunch to conclude the week’s
activities.
To register, complete the application
form and turn it in to your guidance
counselor or mail it to Rhonda Green,
MVCTC, 6800 Hoke Road, Clayton,
OH 45315. The deadline to register is May
17, 2013. A confirmation letter will be
mailed to you prior to Career Camp.
POSSIBLE CAREER EXPLORATION AREAS
COULD BE:
ARTS AND COMMUNICATION
AGRICULTURE/NATURAL RESOURCES
BUSINESS & INFORMATION TECHNOLOGY
HEALTH
HUMAN RESOURCES
BUILDING & CONSTRUCTION
MECHANICAL TECHNOLOGIES
INDUSTRIAL TECHNOLOGY/
MANUFACTURING OPERATIONS
What year will you graduate from high
school? _________________________________
Where do you go to school at:
________________________________________________
________________________________________________
Mother’s Name _______________________________
Phone _________________________________________
Father’s Name _______________________________
Phone _________________________________________
In addition to parents, please list another
emergency contact name and number
__________________________________________
__________________________________________
T- Shirt Size (based on adult size).
Circle choice
XS
S
M
L
XL
2X
3X