SAGES 2022 Mini Medical School Boot Camp Application & Permission Form Saturday, March 19, 2022; 7:30am – 2pm Convention Center in Denver, CO 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 Denver, CO - SAGES Meeting. Lunch will be served. There is no charge for the students to attend the program. Upon completion, each student will receive a certificate of participation as well as the possibility of winning special recognition awards. School Teacher/ Counselor to fill out: School/Student InformationSchool Name:* Student Name:* First Last Student Email Address* Current Grade* 12th 11th 10th 9th 8th Current GPA*Please enter a number from 1.0 to 5.0.Statement of Interest*State a reason why the student is interested in attending our program. Teacher/Counselor Name* First Last Teacher/Counselor PhoneIf knownParent/Guardian/Emergency Contact InformationParent/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, March 19, 2022 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 RecordingI 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. NameThis field is for validation purposes and should be left unchanged.