MAYO CLINIC HEALTH CARE HIGH SCHOOL BOOT CAMP October 26, 2013 CONSENT TO PARTICIPATE

If accepted as a Mayo Clinic HIGH SCHOOL BOOT CAMP participant, I agree that: 1. I shall hold as absolutely confidential all information, whether oral or written, that I may obtain, directly or indirectly, through my participation in the Mayo Clinic High School Boot Camp concerning Mayo Clinic and its operations, patients, visitors, physicians, and other personnel. Additionally, I will not attempt to photograph or solicit an autograph from a patient or visitor. My participation is voluntary to Mayo Clinic without expectation of compensation or future employment and is given for educational reasons. I realize I am never required to perform any services which I am uncomfortable doing or for which I have not been properly trained. I shall not sell or attempt to sell goods or services, request contributions, or solicit persons to sign or distribute political petitions on Mayo Clinic property. I shall report on time and conduct myself with dignity, courtesy and consideration of others. I understand that my appearance while on duty must be neat and clean. I shall resolve any problems related to my High School Boot Camp experience with the event Coordinator. I shall at all times uphold the philosophy and standards of Mayo Clinic and will comply with all policies, rules and regulations of Mayo Clinic. I understand the Mayo Clinic Medical Education Department reserves the right to terminate my participation as a result of: a) Failure to comply with Mayo Clinic policies, rules and regulations. b) Unsatisfactory attitude or appearance. c) Any other circumstances which, in the judgment of the Coordinator would make my continued service contrary to my best interests or those of Mayo Clinic. I have read and understand the contents of this form. If accepted as a Mayo participant I agree to follow all of the above provisions.
Parent/Guardian Name: Date: By checking this box, I attest that the completed information is accurate. Please accept this as my signature.

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Student Name: Date: By checking this box, I attest that the completed information is accurate. Please accept this as my signature.

Please print the requested information neatly. If your responses are not legible, your application will not be considered.
Name: Last First M.I.

Mayo Clinic High School Health Care Boot Camp Reservation Form

Address: City: Home Phone: Birth Date: Month Day State E-mail: Year Age Zip Code

In Case of Emergency, Please Notify (Parent/Guardian Local Person Only) Name: Home Phone: High School Attending (Fall 2013): Current Grade Level (Fall 2013): 9 10 11 12 Relationship: Cell Phone: Business Phone:

REFERRAL: Who referred you to this summer High School Boot Camp? Mayo Employee/Physician: Other: Have you ever served as a Volunteer? If yes, where? Yes No Relative/Guardian:

LATEX SENSITIVITY/ALLERGIES: Do you have a latex sensitivity or allergy? (Please check one) No Yes If yes, please list:

PHOTOGRAPHY CONSENT: Consent to photograph High School Boot Camp participants for use in class related activities and workshop completion ceremony. No external use unless a separate release form is signed. Parent/Guardian Signature: Date: By checking this box, I attest that the completed information is accurate. Please accept this as my signature. Student Signature: Date: By checking this box, I attest that the completed information is accurate. Please accept this as my signature.

ESSAY: Please briefly tell us why you want to participate in the Mayo Clinic High School Boot Camp.