Student Information. Parent/Guardian Information

Transcription

1 Student Information Stude t s Na e: Called: Home Address: City/State/Zip: First M. Last Home Phone: ( ) - Stude t s Age: Grade Parent/Guardian Information Mothe s Na e: Day Phone #: ( ) - Fathe s Na e: Day Phone #: ( ) - Who is Addition to the parent/guardian is authorized to pick up the student? 1.) Name: _ Phone #: ( ) - 2.) Name: _ Phone #: ( ) - 3.) Name: _ Phone #: ( ) - Medical Information Emergency Contact: Emergency Contact #: ( ) - Do to s Na e: Phone #: ( ) - Hospital Preference: Please list any medical conditions that e ui e a do to s a e: Please list any medications that the student is currently taking: A e you hild s i u izatio s u e t? Yes No Please list any allergies: Please list any physical limitations: Additional Information: Please note that your child may be photographed during camp and the picture used in flyers or the website. However, we will not release any names or personal information. Printed Name of Parent/Guardian: Signature: Date:

2 Proof of Health Insurance Please complete one form per student showing the health insurance coverage you currently carry: Name of Insurance Carrier: Name of Insured: Name of Dependent child: Group number: Policy number: Effective Date of Coverage: Signature of Insured Date

3 Please complete one form per student. Waiver of Liability SOUTHERN POLYTECHNIC STATE UNIVERSITY ASSUMPTION OF RISK (BINDING LEGAL DOCUMENT READ CAREFULLY BEFORE SIGNING) SUMMER CAMP ACTIVITES Name of Event: Dept. of Mechanical Engineering Technology / 3D Printing and Design Camp 2014 Date of Event: Summer Camp Activities (including, for purposes of this Agreement, all instruction, practice, and competition in cheerleading, dance, marching auxiliaries, and related activities, including transportation to and from events or off-site locations) may involve risks of bodily injury, property damage, and other dangers associated with participation in such activities. Dangers related to such activates may include but are not limited to: loss of or damage to personal property, broken bones, strains, sprains, bruises, drowning, concussion, heart attack, heat exhaustion, injuries associated with travel, and death. The parent or guardian of each minor participant in Summer Camp Activities acknowledges and accepts these risks. The decision to permit participation is solely that of the parent or guardian; participation is completely voluntary. As the undersigned parent or guardian, I acknowledge that Southern Polytechnic State University does not warrant or guarantee in any respect the competency or mental or physical condition of any instructor, leader, vehicle driver, or individual participant in any Summer Camp Activity. I further acknowledge that Southern Polytechnic State University makes no warranty as to the condition, safety, or suitability of any equipment, vehicle, property or premises for any purpose. The parent or guardian of each participant in voluntary Summer Camp Activities is required to sign this Release, Waiver of Liability and Covenant Not to Sue form. I acknowledge that I am solely responsible for any hospital or other costs arising out of any bodily injury or property damage sustai ed th ough y i o hild o a d s pa ti ipatio i su h olu ta y Su e Ca p A ti ities. I acknowledge that Southern polytechnic State University does not provide insurance coverage for my minor child or ward. I have read and understand this document. I understand that I will be provided with a copy of this document upon request. On my behalf and on my minor child or ward, I accept and assume all risks, hazards, and dangers involved in such Summer Camp Activities in which I may elect to allow my minor child or ward to participate, including the preparation for, and travel to and from the site of such activities. Printed Name Signature RELEASE, WAIVER OF LIABILITY AND CONVENANT NOT TO SUE

4 (BINDING LEGAL DOCUMENT READ CAREFULLY BEFORE SIGNING) I hereby agree that for the sole consideration of Southern Polytechnic State University allowing my minor child or ward to participate in voluntary Summer Camp Activities and in connection therewith, making available to such minor or ward for his or her use while participating in such summer Camp Activities, certain equipment, vehicles, facilities, grounds, or personnel of Southern Polytechnic State University, on my own behalf and on behalf of my minor child or ward, I do hereby waive liability, release and forever discharge Southern Polytechnic State University and the Board of Regents of the University System of Georgia, their members individually, and their officers, agents contractors, volunteers, and employees, and the Georgia State Tort Claims Trust Fund, of and from any and all claims, demands, rights, and causes of action of whatever kind or nature, arising out of all known and unknown, foreseen and unforeseen bodily and personal injuries, damage to property, and the consequences the eof, i ludi g death, esulti g f o y i o hild o a d s voluntary participation in or in any way connected with such Summer Camp Activities, including without limitation travel. I further covenant and agree that for the consideration stated above I will not sue Southern Polytechnic State University or the Board of Regents of the University System of Georgia, their members individually, their officers, agents, contractors, volunteers, or employees, or the Georgia State Tort Claims Trust Fund, for any claim for damages arising or growing out of y i o hild o a d s olu ta y pa ti ipatio i Su e Ca p A ti ities at o i o ju tio ith Southern Polytechnic State University. I understand that the acceptance of this release, waiver of liability, and covenant not to sue Southern Polytechnic State University or the Board of Regents of the University System of Georgia or any officer, agent, volunteer, or employee thereof, or the Georgia State Tort Claim Trust Fund, shall not constitute a waiver, in whole or in part, of sovereign, governmental, or official immunity by said Board, its members, officers, agents, volunteers, and employees. I understand that I will be provided a copy of this document upon request. I certify that I am over 18 years of age and suffering under no legal disabilities and that I have read the above carefully before signing. This day of, 2014 Printed name of parent or guardian Printed name of student Signature of Parent or Guardian Witness (18 or older)

5 3D Printing and Engineering Design Summer Camp Student Agreement All participants of the Aerospace Engineering summer camp are required to read the following instructions. Please sign and date below. Safety Food Students a e ot to ope ate a y e uip e t ithout the a p di e to s pe issio Students are requested to stay inside the building during the breaks Students are welcome to bring their own equipment that they feel is relevant to the camp. Its demonstratio / usage a e su je t to i st u to s pe issio. Stude ts ill e espo si le fo safety and handling of their own equipment Students are requested to bring their own food. There will be a lunch break and breaks for snacks during the day. Punctuality Dress Students are requested to be punctual Students need to be dropped off and picked up punctually every day. After the camp ends, it is the pa e t s o gua dia s espo si ility to pi k up the stude t i a ti ely a e at the e d of the day. Casual attire and comfortable (closed) footwear is recommended. (Sneakers / running shoes will be ideal for field trips) Miscellaneous Students are required to clean after themselves Instructor should be notified of any students with special needs or medical conditions Student Name (Please Print) Student Signature Date Parent Name (Please Print) Parent Signature Date