EKU Educational Talent Search Program Student Leadership Team 2018-19 Dear ETS Participant, You have indicated an interest in being on the ETS Student Leadership Team. It will be necessary for us to meet several times though-out the year. The Leadership Team will be instrumental in making some decisions regarding upcoming ETS activities, with specific focus on summer activities. YES, I wish to participate in ETS Student Leadership Team. I can attend the following ETS Student Leadership Team meetings, on or near the Eastern Kentucky University campus. Specific meeting location to be announced. Saturday, October 6, 2018 Saturday, February 2, 2019 Saturday, November 3, 2018 Saturday, March 2, 2019 Saturday, December 1, 2018 Saturday, April 6, 2019 Saturday, January 5, 2019 Saturday, May 4, 2019 NAME: SCHOOL: GRADE: Home Mailing Address: E-mail Address: Facebook Name: Student Cell Phone: May we text you? Parent/Guardian Name: Parent/Guardian E-mail: Parent/Guardian Phone/Home: May we text this number? Permission to Participate & Photo Inclusion in ETS Student Leadership Team Sponsored by the EKU Educational Talent Search Program Student Name: I hereby grant permission for my son/daughter to participate in any ETS Student Leadership Team Activity sponsored by Eastern Kentucky University s Educational Talent Search Program. I give permission to the EKU Educational Talent Search Program to take photos of the ETS Leadership Team activities and permission to post the photos to the ETS Facebook social media page. Signature (ETS Student) Signature (Parent/Guardian) Date
Waiver of Liability, Assumption of Risk, and Indemnity Agreement Educational Talent Search Program Eastern Kentucky University THIS IS A LEGALLY BINDING RELEASE, WAIVER, INDEMNIFICATION OF LIABILITY, AND EXPRESS ASSUMPTION OF RISK. ***Please read it carefully, fill in all blanks and initial each paragraph before signing.*** I, (parent/guardian s name), hereby affirm that I have read this document in its entirety. By my signature below and by my initialing each paragraph, I agree to each and every term and condition of this document. I UNDERSTAND THAT PARTICIPATION IN the EKU Educational Talent Search Program Student Leadership Team (hereafter referred to as Event, which involves van transportation to and from activities during each event, CARRIES WITH IT CERTAIN INHERENT RISKS AND DANGERS. THESE RISKS INCLUDE, BUT ARE NOT LIMITED TO: PERSONAL DAMAGE, INJURY, PARALYSIS, LOSS, DEATH OR PROPERTY DAMAGE OR LOSS. I understand that these risks are described by way of example only, and that there are numerous other risks inherent in this activity to which I may be exposed. In the event of possible injury, I give permission for EKU to authorize the administration of medical care. IN CONSIDERATION OF BEING PERMITTED TO PARTICIPATE IN ANY WAY IN: the event. I, on behalf of myself and anyone claiming interest through me, DO HEREBY INTENTIALLY, KNOWINGLY, AND VOLUNTARILY RELEASE, WAIVE, DISCHARGE, INDEMNIFY, AND AGREE TO HOLD HARMLESS EASTERN KENTUCKY UNIVERISTY, and all its employees, regents, and volunteers FROM ANY AND ALL CLAIMS, ACTIONS, SUITS, PROCEDURES, COSTS, ESPENSES, DAMAGES, AND LIABILITIES brought as a result of my involvement in this event, whether such damage, injury, or loss results from NEGLIGENCE or some other cause, and to reimburse them for any such expenses incurred. I understand that at times participants may be together in groups that are not under direct supervision of Educational Talent Search. I understand that the University in no way represents, or acts as an agent for, any third party trip organizer, the transportation carriers, hotels, and other suppliers of service during this event. I understand and agree that the University is not responsible for losses or expenses due to sickness, weather, strikes, hostilities, wars, natural disasters, or other such causes or disruptions. Further, the University is not responsible for any disruption of travel arrangements, or any consequent additional expenses that may be incurred therefrom. I desire to have my child travel with the University s Group. I fully understand and appreciate the dangers, hazards, and risks inherent in the transportation to, from, and during this event, which dangers include, but are not limited to serious or even mortal injuries and property damage. I HEREBY ASSERT THAT MY CHILD S PARTICIPATION IS VOLUNTARY AND THAT I KNOWLINGLY ASSUME ALL SUCH RISKS. I understand that I signed this document as my own free act and deed: no oral representations, statements, or inducements, apart from the foregoing written statement, have been made. I further agree that this document will be interpreted in accordance with the laws of the Commonwealth of Kentucky. If any term or provision of this document shall be held illegal, unenforceable, or in conflict with any law governing this document, the validity of the remaining portions shall not be affected. ETS Participant s Full Name: Birthdate Student Signature Date Parent Signature Date
Student Health History and Parent Consent Form Educational Talent Search (ETS) Program Eastern Kentucky University ETS Student Leadership Team Participation Student: School Grade Last First MI Home Mailing Address: (Street, Apt. No.) City Zip Code Home Phone: Parent/Guardian Cell Phone: Health Insurance Provider Policy # Student is not covered by any Health Insurance. Student s date of Birth: Height: Weight: Does student have any limiting physical or health disabilities (whether temporary or permanent) that you or your doctor feel would limit safe participation in the named program/activity? Yes No Does student have any chronic or recurring injuries? Yes No Has student had a kidney transplant? Yes No Is student pregnant? Yes No Current Health Status: Using the health checklist, please indicate if you have any physical disabilities or conditions that would limit participation in the Educational Talent Search (ETS) Program activity. If you are unsure of your activity level, please explain the program to your physician and ask for his/her advice. Health Checklist: Please check the following physical disabilities or conditions you have that may limit your participation. Hearing or vision problems Frequent muscle cramps Respiratory problems High or low blood sugar Back problems Seizure disorders Joint problems Reactions to altitude Recent serious illness Heart problems Recent surgery Asthma Recent hospitalizations Serious reaction to high or low temperatures Other condition not listed: If you checked any of the above, please give details including any restrictions you may have Allergies: Indicate any allergies (including medications), your reaction, and treatment. Allergy Reaction Treatment Medications: What are you currently taking, for what, and will you need it during the named program? If you need it, make sure you have ample supply for the program. Medication Condition Need medication during program? Yes No Yes Yes No No
Current Physical Condition: Please check the highest activity level in each category that you feel you can comfortably attain. Walking 2 miles in 40 min. 4 miles in 80 min. 6 miles in 120 min. Unsure Jogging 1 mile in 12 min. 3 miles in 36 min. 5 miles in 60 min. Unsure Cycling 5 miles in 30 min. 10 miles in 60 min. 20 miles in 120 min. Unsure Current Exercise Activity: List any physical activities you engage in, their frequency, duration, and level of intensity. Activity Times/Week Approximate time/distance Low Moderate High Swimming Ability: non-swimmer poor fair good very good Parent/Guardian Permission: I hereby give permission for, to participate in the Educational (Name of ETS Student) Talent Search (ETS) STUDENT LEADERSHIP TEAM MEETINGS & ACTIVITIES: Saturday, October 6, 2018 Saturday, February 2, 2019 Saturday, November 3, 2018 Saturday, March 2, 2019 Saturday, December 1, 2018 Saturday, April 6, 2019 Saturday, January 5, 2019 Saturday, May 4, 2019 In case of an injury, I grant permission for (student) to receive medical attention deemed necessary, by qualified medical personnel, during the entire time that he or she (listed within) is participating in the ETS Field Trip. PARENT/GUARDIAN: Every reasonable precaution will be taken to provide safety and care for your son/daughter. Every effort will be made to notify you in the event of an accident or injury, which may require emergency care. If you cannot be contacted, permission is granted to the staff to seek medical attention. All financial responsibility for hospitalization and medical care provided, in the case of an emergency, is to be assumed by the parent or guardian. Signature of Parent/Guardian (if student is under the age of 18) Date Emergency Contact Information: Person to notify in case of emergency: Name: (print) Phone: Other Phone: Relationship to student: Address: If the above individual cannot be contacted, please give a second emergency contact: Name: Phone: Other Phone: Relationship to student: Address: This form must be returned along with ETS activity registration materials. (Revised 9/10/2018)
Please RETURN all Registration Materials no later than SEPTEMBER 28, 2018 VIA US Mail to: Educational Talent Search Program Telford House, 521 Lancaster Ave. Richmond, Ky 40475 Dropped off in person at: Telford House 252 Summit St., Richmond, KY Faxed to: 859-622-5033 Scanned & Emailed to: ETS@eku.edu Or take a photo of each page and send them to the above email or Private-message all the pages via the ETS Facebook Messenger.