Summer Camp Application INTERNATIONAL DEVELOPMENT 101

Transcription

1 INTERNATIONAL DEVELOPMENT 101 Student Information Student Name: Sex : Male / Female Student Preferred/Nickname: Mailing Address: Home Phone Number: Cell Phone Number: School: Grade (Entering): Date of Birth: Parent Information In Case of Emergency Parent #1/ Guardian Name: Cell Phone Number: Employer: Work Phone Number: Parent #2/ Guardian Name: Cell Phone Number: Employer: Work Phone Number: Parent / Guardian Person to contact if we can t reach you: Name: Relationship to Student: Home Phone: Cell Phone: Medical/Health/Insurance Care Information Student s Doctor Name: Address: Office phone number:

2 Medical/Health/Insurance Care Information (Continued) Health Insurance Company: Group or Policy Number: Telephone Number: PLEASE ATTACH A PHOTOCOPY OF THE STUDENT S HEALTH INSURANCE CARD Medications: Allergies: Immunizations: Dietary Restrictions: Other information about health conditions and/or special needs (please use back of page if necessary): Emergency Medical Information I hereby give consent to treat in case of a medical emergency. I understand that all efforts will be made to contact me immediately. Signature of Parent or Guardian Date

3 Student Essay We have found that the students who love this summer program have a strong interest in the global community and international development. In an effort to learn more about the student, please have him/her answer the questions below. The essay response should be submitted with your application. Please note, this essay is solely intended to make sure the program is a good fit for the student s interest. STUDENTS: Please send a short response to the following questions with your registration forms. You may write in the space provided below, or type your responses. What interests you about international development? Why do you want to attend summer camp at Mercy Corps?

4 Media Release Occasionally we take photos or video footage during class for use in our print materials and other public media. Do we have your permission to use your child s image? YES NO Student will attend all hours and days of camp YES NO Payment Information Payment is required for registration. Students who cancel their enrollment two or more weeks before the first day of the summer camp receive a full refund; those who cancel less than two weeks before receive a 50% refund. There are no refunds for students who cancel any time during the summer camp. Note: Payment will not be processed until your child has been accepted into the program and a confirmation has been sent. I paid over the phone, to pay with a credit card please call (503) I paid in person at the Action Center My check is enclosed When Complete, mail all forms to: Mercy Corps Action Center 2014 Summer Camps 45 SW Ankeny Portland, OR *We will confirm the receipt of the application once it has been processed. Program acceptance will be based on the date application is received, the student s ability to attend the program in its entirety and the essay response.

5 PARENTAL PERMISSION AND MEDICAL CONSENT WITH LIABILITY RELEASE Student Name Birth date Social Security Number Address The undersigned(s) being the lawful parent(s) and/or guardian(s) of the above student (the "Student"), hereby consent(s) to the participation by the Student in the International Development 101 Summer Camp taking place in and around Portland, Oregon on July 21, 2014 through July 25, 2014 (hereinafter the Program ), and to the participation of the Student in all events relating to the Program, including travel to and from the Program. BY SIGNING BELOW, I AGREE TO ASSUME ALL RISK OF INJURY OR HARM TO THE STUDENT ASSOCIATED WITH PARTICIPATION IN THE PROGRAM, AND AGREE TO RELEASE, INDEMNIFY, DEFEND AND FOREVER DISCHARGE MERCY CORPS, ITS OFFICERS, DIRECTORS, EMPLOYEES, VOLUNTEERS, SUBSIDIARIES AND AFFILIATES (COLLECTIVELY MERCY CORPS ), FROM AND AGAINST ALL CLAIMS, LIABILITIES, LOSSES, SUITS OR EXPENSES (INCLUDING COSTS AND REASONABLE ATTORNEYS FEES) MADE OR BROUGHT BY ANYONE, INCLUDING A CO-PARTICIPANT, THIRD PARTY, THE STUDENT, OR ANY MEMBERS OF THE STUDENT S FAMILY ARISING OUT OF ANY INJURY, DAMAGE, DEATH, OR OTHER LOSS IN ANY WAY CONNECTED WITH THE STUDENT S PARTICIPATION IN THE PROGRAM OR RELATED ACTIVITIES.THIS AGREEMENT INCLUDES ANY LOSSES CLAIMED TO BE CAUSED, IN WHOLE OR IN PART, BY THE NEGLIGENCE OF MERCY CORPS. I AGREE TO WAIVE ALL CLAIMS AGAINST MERCY CORPS, AND AGREE THAT NEITHER I, NOR ANYONE ACTING ON MY BEHALF, WILL MAKE A CLAIM OR FILE A LAWSUIT OF ANY KIND AGAINST MERCY CORPS, AS A RESULT OF ANY INJURY, DAMAGE, DEATH OR OTHER LOSS SUFFERED BY THE STUDENT. The undersigned hereby further authorize(s) any of the staff, employees, agents and representatives of Mercy Corps to provide for, approve and authorize any health care at any hospital, emergency room, doctor s office or other institution; employ any physicians, dentists, nurses, or other person whose services may be needed for such health care; review and if necessary disclose the contents of any medical records; execute any consent form required by medical, dental or other health authorities incident to the provision of medical, surgical or dental care to the Student. Health care shall include but not be limited to the administration of anesthesia, X-ray examination, and performance of operations, diagnostic and other procedures ( Health Care ). The undersigned assume(s) and agree(s) to pay all costs associated with any Health Care authorized by Mercy Corps on behalf of the Student, and hereby release(s) Mercy Corps from all costs associated with such Health Care. If there is no medical emergency, Mercy Corps will first use reasonable efforts to contact the parent(s) and/or guardian(s) before administering or authorizing any treatment. Notwithstanding other provisions in this Consent Form, Mercy Corps shall not have the authority to withhold or withdraw life-sustaining procedures for the Student.

6 The undersigned further permits Mercy Corps, its staff, its agents, and news media outlets to photograph, post online, videotape, or by any other means record the Student s image or voice or writing for the purpose of instructional, promotional or archival use. This Consent Form may be revoked at any time before the student begins participation in the Program with written notice to Mercy Corps. This Consent Form shall be governed by the laws of the State of Oregon, without regard to its conflict of laws principles. Any dispute between the parties arising from Consent Form shall be exclusively resolved in state or federal court in the State of Oregon, and in such case the parties consent to personal jurisdiction in the State of Oregon. I HAVE READ THIS CONSENT, WAIVER AND RELEASE OF LIABILITY, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE ASSUMED RISKS AND GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT. Signature of Student Date Name (please print) of Parent/Guardian Signature of Parent/Guardian Date