Howard Community College

(continued on back) Kids on Campus Consent Form 2020 * = Required Information Online consent form also available at howardcc.edu/kocconsentform Student Name* __________________________________________________________________________________ Parent/Guardian Name* ____________________________________________________________________________ Student Birth Date* _______________________________________ Age* __________________________________ Student Home Address: (Street)* ______________________________________________________________________ City* ____________________________________________________ State* ____________ Zip* _________________ Parent/Guardian Preferred Phone Contact Number* ________________________________________________________ Valid Parent/Guardian Email* ________________________________________________________________________ EMERGENCY CONTACT INFORMATION – Alternate person to contact in the event of an emergency (two required) Name of Alternate Emergency Contact* _________________________________________________________________ Alternate Emergency Contact Daytime Phone* ____________________________ Relationship* _____________________ Name of Alternate Emergency Contact* _________________________________________________________________ Alternate Emergency Contact Daytime Phone* ____________________________ Relationship* _____________________ HEALTH INFORMATION FOR THE STUDENT Name of Physician or HMO* _________________________________________________________________________ Physician Phone Number* __________________________________________________________________________ Are there any health problems including physical, psychiatric, or behavioral problems of which we need to be aware? No Yes, explain: __________________________________________________________________________________ Are there any medications, dietary restrictions, allergies, or special needs that we need to be aware of to ensure that your child's KOC class experience is positive? (see Policies and Procedures for accommodation information) No Yes, explain:__________________________________________________________________________________ SCHOOL INFORMATION Is your student currently enrolled in a public or private school in the U.S.?* Yes No If yes above, full name of school attended (2019-20)*__________________________________ 2019-20 Grade* _______ School Address*__________________________________________________________________________________ City* __________________________________________________________ State* __________ Zip* ____________ For students who currently reside within the United States, a United States territory, or the District of Columbia: Does the student have any immunization exemptions because of a parental or guardian objection or medical contraindication: No Yes, list:_____________________________________________________________________________________ For students who reside outside the United States, a United States territory, or the District of Columbia: Attach or submit a record of vaccination or immunity in English on Department form MDH-896.

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