Please fill out the following form:

First Name	*REQ
Last Name	*REQ
School Name	*REQ
E-mail	*REQ
Student Address	*REQ
Address (cont.)
City	*REQ
State	*REQ	Zip	*REQ
Student Phone	*REQ
Emergency Contact	*REQ
Emergency Phone	*REQ
School Contact	*REQ
School Contact's Phone/E-mail	*REQ
Student ID
Grade:	*REQ	Gender: M/F	*REQ

y/n *REQ IMPORTANT: I have completely filled out this form, printed it and will bring it with me to the event. I understand I will not be allowed to attend the event unless accompanied by this form with written parental/guardian signature. If you are lost call .

The undersigned student is participating in the Tuality & School to Work Career Event. By signing below the student and guardian acknowledge understanding that Tuality Healthcare & STW has no liability for this activity. The undersigned agree that each participant is responsible for his/her own safety and agree not to look to Tuality Healthcare or other involved parties with regard to liability for any claims related to participation in the Tuality & STW Career Event activities. The student agrees to attend and participate fully in the entire program. It is understood that this is a learning event and the students agree to conduct themselves appropriately as representatives of their school. Parent: By signing below you are confirming that the student’s immunizations are current, including: Measles, Mumps, Rubella and Varicella (Chicken Pox – by disease or vaccine). Other suggested immunizations include: Hepatitis B, Influenza and Tetanus. Student by signing below you acknowledge that you have read, understand and agree to comply with the Tuality dress code.

Parent Signature: _____________________________Student Signature: _________________________________