Medical Authorization

I certify that my child is in good physical and mental health and my child has no special medical or physical conditions which would impede participation in the MassPep STEM Program.

I agree to disclose to MassPep any medications and/or prescriptions which my child shall or should take at any time during the program. In the event of a serious illness or injury to my child, I expressly consent by my signature to the administration of emergency medical care, if in the opinion of the attending medical personnel, such action is advisable.

I certify that I am the parent or legal guardian of the applicant, that I have read and that I understand the above Agreement. I accept and will be bound by this agreement’s terms and conditions on my own and my child’s behalf.
I give permission for
to participate in the student MassPep Summer STEM Program.