Parental Permission – International Institute for Astronautical Sciences

Parental or Guardian Permission and Medical Release Activity: AST 101: Advanced PoSSUM Academy at Florida Tech and at the Southern Aeromedical Institute

04/23/2024

Participant's Name

First Last Suffix

Participant's Date of Birth

Home Phone

Work Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Medical Information
If the adolescent has recently experienced any of the medical conditions below they are unable to participate in the Altitude Chamber portion:

Recent Head or Chest Cold

Yes
No

Chronic or Recurring Ilness

Yes
No

Chronic Allergies

Yes
No

Vomiting or Diarrhea Within the Last 48 Hours

Yes
No

Asthma

Yes
No

Epilipsey

Yes
No

Migraine Headaches

Yes
No

Other Medical Condition Requiring Treatment

Yes
No

Additional Information

If you have answered yes to any of these questions, please provide additional details.

Approval*

I give permission for my child / youth to participate in the activity listed above and authorize the adult leader supervising this activity to administer emergency medical treatment to the above named participant for any accident or illness, and to act in my stead in approving necessary medical care.

Parent or Guardian's Name

First Last

Date

Project PoSSUM, Inc. International Institute for Astronautical Sciences (DBA) 1830 22nd Street Suite 6 Boulder, CO 80302 astronauticsinstitute.org

Parental Permission Slip