Emergency Contact - Waiver Of Liability
ADVERTISEMENT
1
2FALL
SPRING
SUMMER
YEAR:
CHAFFEY COLLEGE
EMERGENCY CONTACT INFORMATION AND INTERNET USAGE
(Required for students under 18 years of age)
Please Print – Use Black Ink Only
Student Name
Chaffey ID #
Last
First
MI
Student Address
Number
Street
Apt.
City
State
Zip
Telephone (
)
Date of Birth
SS# (optional)
EMERGENCY CONTACT INFORMATION
IN CASE OF ACCIDENT OR SUDDEN ILLNESS, PLEASE CALL:
(
)
Last
First
Relationship
Telephone
Should an emergency arise, requiring immediate medical attention while attending Chaffey College and a parent or
guardian cannot be contacted, Student Health Services is authorized to take whatever steps are needed to protect the
health of the student.
Student’s Signature
Date
Parent’s Signature
Date
Guardian’s Signature
Date
NOTIFICATION REGARDING INTERNET ACCESS
Many college courses now require computer lab work or research projects involving the use of the Internet. Chaffey
Community College District’s computer network does provide access to the Internet
This notice is to advise parents/guardians of students under the age of 18 that the college does not block access to the
Internet. As a result, it is possible for your daughter/son to reach an Internet site that you may feel contains
inappropriate material.
Your approval, as indicated by your signature on this form, is required for your daughter/son to have access to the
college’s computer network system and to enroll in courses at Chaffey College.
Parent’s Signature
Date
Guardian’s Signature
Date
TO STUDENT: Fax this form along with the Liability Waiver form to (909) 652-6617. To verify that we have cleared your
restriction, log onto MyChaffeyVIEW and on the Student Menu, select the option “View My Restrictions”. Use the Tutorial
Video for help on logging into the system.
OFFICE USE ONLY
Received in Admissions on:
Restriction cleared by:
(Revised: 07/28/09)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business