FutureU Student

Contact, Permissions & Health Information Form

The FutureU Health Waiver must be completed once per student per semester.

If not available in an emergency, notify:

I hereby irrevocably release, consent and allow Washtenaw Community College and its agents to use and reproduce any and all photographs or video footage taken of me or my dependent(s) for WCC purposes. I understand that I/my dependent(s) receive no reimbursement for allowing my photo to be taken or for the use of the photo or video.

I hereby consent to the full participation of the aforementioned participants in the registered program. I release and hold harmless Washtenaw Community College, its officers and employees, from all liability for any injury or damage to person or property howsoever caused, resulting from participation by the aforementioned participant in the program.

I have read and understand in full the content of the Parent Packet. Furthermore I agree to follow the policies and guidelines covered in the packet.

I give permission to Washtenaw Community College to provide emergency health care, dispense medications and secure emergency medical and/or emergency surgical treatment to my child while in care.

The camper may be picked up from WCC programs by the following person(s):

OR, WCC has my permission to release the above named participant to the following people upon showing photo ID:

*Example:

• Babysitter Name and Number
• Grandma Name and Number
• Aunt Name and Number

WCC FutureU Staff will not hold or dispense medication. If your student requires routine medication, please list below and contact somccain@wccnet.edu.

(To medicine, food, insect stings or bites, etc.)

Please check below if the participant has or has had any of the following medical problems:

IF APPLICABLE, PLEASE ATTACH COPY OF ASTHMA PLAN AND/OR ALLERGY PLAN