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 503.335.3500. All students are accepted unless notified.

The undersigned student is participating in the Legacy Health High School Interactive Health Career Day. By signing below the student and parent/guardian acknowledge understanding that Legacy Health 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 Legacy Health or other involved parties with regard to liability for any claims related to participation in the Career Day 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. Dress code: business casual (no jeans, shorts, short skirts, sweat pants or flip-flops. No cleavage or midriff showing. Clean clothing/no rips or baggy pants.) 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). Suggested immunizations include: Hepatitis B, Influenza and Tetanus.

Parent Signature: _____________________________Student Signature: _________________________________