SELECT Workshop ConsentForm


    TheSELECT (Schuylkill Education Leading to Employment and Career Training)Pregnant and Parenting Teen Program is offering __________________________the opportunityto participate in a workshop on various parenting and career readiness topics.


    Where: ________________________                               When: _________________





    Emergency Information

    In theevent of an accident/emergency, I hereby authorize the Intermediate Unitpersonnel to secure any necessary medical treatment for my child and I herebyrelease and agree to indemnify and save harmless the Schuylkill IntermediateUnit #29, the Board of Directors and the Intermediate Unit personnel from allliability in the performance of their duties and in securing emergency medicaltreatment.




    _______________________                                             _______________________        

    ContactPerson                                                                       Parent/GuardianSignature







    The SELECTProgram is a service offered at __________________ and participation in thisworkshop has school approval (excused absence).  The student is responsible for completing anymissed schoolwork.



    _____________________________                                   _______________

    SchoolCounselor’s Consent                                                  Date


    _____________________________                                    _______________

    Parent/GuardianConsent                                                       Date


    Lifelong Learning Center

    2221 W Market St

    (570)628-5761  Fax (570)628-5765


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