2017 cougar discovery student information packet · title: microsoft word - 2017 cougar discovery...

2017

Cougar Discovery Student

Information

PLEASE PRINT

Student Name: ______________________________________________________________________________________________ First Middle Last

Male Female High School: ____________________________________________________________________________

Fall 2017 Grade Level (check one): 9th 10th 11th 12th Birth date: month ______ day ______ year _________

Mailing Address: ____________________________________________________________________________________ Street Address

_____________________________________________________________________________________________ City State Zip Code

Contact: ____________________________ ____________________________________________________________________ Phone Number Email Address

Contact information for parent/guardian with residential placement and/or decision-making authority in the event of illness or injury for this student:

Name: Relationship to Student:

Preferred Phones: ( ) ( ) E-mail:

Home Address: (If different from above) Street Address

City

State

Zip Code

Second parent/guardian with legal custody to be contacted in case of illness or injury:

Name: Relationship to Student: ______________________________


Emergency contact in case of illness or injury if persons listed above cannot be reached:

Name: Relationship to student: ________________________________


Allergies: Check any that apply to this student

No known allergies.

This student has a life-threatening allergy. If this box is checked, an emergency care plan signed by physician must be provided.

This student is allergic to: (Please list, describe reaction seen and preventative or responsive measures.)

Medicine:

Environmental (insect stings, hay fever, etc.)

Other:

Food Allergy(s)/Intolerances: Please provide medical documentation describing the dietary restrictions due to the food allergy and/or intolerance from the Participant’s Physician (MD or DO). CHECK ALL THAT APPLY:

Food Allergy: Dairy ______ Soy ______ Eggs ______ Peanuts ______ Tree Nuts ______ Fish ______ Shellfish ______ Wheat ______

Other, please list: _________________________________________________________________________________________________________

Food Intolerance: Gluten (celiac disease or non-celiac gluten sensitivity, includes wheat, barley, oats, rye) _________ Lactose ______ MSG ______ Other, please list: ____________________________________________________________________

Other Special Diet needs or restrictions (i.e., Diabetes, IBS, other), please explain:

Types of contact that will cause a reaction: Airborne _______ Trace Cross-Contact _______ Actual ingestion of food _______ Other ________ Please explain reaction:

Food Allergy(s)/Intolerances: WSU Tri-Cities and its food vendors does not provide assistance or administer injections due to allergic reactions and does not carry or provide stock epinephrine. Every attempt to meet special diet and food allergy needs will be made, but it is not possible to guarantee food service for all food allergies. Students with specific dietary needs are welcome to bring their own lunch each day.

IMPORTANT! Please provide a written document explaining that the Participant understands his/her food allergy and what needs to be done to manage it including any information you would like to share to help us meet the Participant’s need.

Mental, Emotional, and Social Health: Check “Yes” or “No” for each statement. Has the student:

1. Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (ADHD)?………………………….. Yes No

2. Ever been treated for emotional or behavioral difficulties or an eating disorder………………………………………….….…………………….. Yes No

3. During the past 12 months, seen a professional to address mental/emotional health concerns………………..…….…………………….. Yes No

Please explain “Yes” answers in the space below, noting the number of the question. The program may contact you for additional information.

Immunizations:

My student is up-to-date on his/her immunizations and tetanus shots as required by Washington State law.

My student has an immunization exemption on file with his/her school. I understand and accept the risks to my student from not being fully immunized.

Medications: (“Medication” is any substance a person takes to maintain and/or improve their health; this includes vitamins and natural remedies.)

Washington State University staff cannot administer medication to children. If your student requires a dosage during camp hours, please make appropriate arrangements. All medications sent with the student to campus must be in their original containers. Prescriptions must have the student’s name and how the medication should be given printed on the prescription container. Please send only those medications that are necessary.

This student will not take any daily medications while attending the activities.

This student will be self-administering medication(s) while attending the activities.

Name of medication Date started Reason for Taking When it is given Amount or dose given How it is given

Lunch

Other time: _________

Lunch


Lunch


Restrictions and Accommodations: Check all that apply. Attach additional pages for descriptions if needed.

I feel my student can participate without restrictions.

I feel my student can participate with the following restrictions or adaptations. Please describe below.

My student does not require reasonable accommodation for a disability in order to access or be part of the activities.

I request reasonable accommodation for a disability in order for this student to access or be part of the activities. Please describe below:

Emergency Medical Release: In an emergency requiring medical attention or a situation reasonably believed by Washington State University (WSU) authorized agents to be an emergency, I authorize WSU and its authorized agents to obtain emergency medical care for my student. I will be responsible for any expenses incurred in so doing including but not limited to care by health care professionals, hospital care, and ambulance or other services. In addition, the health care provider has permission to obtain a copy of my student’s health record from providers who treat my student and these providers may talk with the program’s staff about my student’s immediate health status. NOTE: Minors may consent to certain services in Washington. I hold harmless and agree to indemnify WSU, its authorized agents and employees from decisions to seek emergency treatment.

Health-Care Providers:

Name of Primary Doctor(s): ______________________________________________ Phone: (___________)________________________________

Medical Insurance Information: This student is covered by family medical and/or hospital insurance. No Yes, information is provided below:

Primary Insurance Company:

Policy Number:

Subscriber: Insurance Company Phone: ( )

Image and Voice Recordings Consent: WSU may share pre-college programming on its website for the enjoyment of students, their family, and friends. Local media often request to attend these programs to capture the students’ learning activities to share with their viewing audiences. Please let us know of your preferences:

Yes: Images or voice recordings may be used as set forth below. No: Images or voice recordings may not be used as set forth below. Permission is granted to WSU for the student to be photographed or otherwise have images or voice recordings made (including but not limited to photographs, moving

images and/or voice recordings), for WSU publication or promotional purposes in any medium (including but not limited to print and digital media). The student’s name and/or interview comments may be used in connection with WSU publication or promotional purposes in print media, newspaper, television, video,

motion picture, or other electronic media. The use of the student student’s likeness or voice recordings is not a condition of participating in the activity and that consent may be refused without any impact in the

ability to fully participate in the program. No inducements or promises beyond this acceptance of an opportunity to promote WSU and its programs have been given to the persons signing below. Any other use of images and/or recordings, names, and/or interview comments requires advance permission. The Image and Voice Recordings Consent may be revoked at any time upon notice to WSU, at which time the parent/guardian will sign a copy of the denial for use of

images or voice recordings.

Transportation Authorization: Please check the boxes below as your authorization for approved transportation methods to be used by your student to leave Cougar Discovery and the WSU Tri-Cities campus, at the end of the program day or, with prior written notification by you to the program director, leave during a program day for medical or other appointments. All participants are asked to arrive at WSU Tri-Cities CIC Building by 8:30 a.m. each day prepared to follow instructions.

My student has my authorization to travel alone, and/or leave campus with a family or non-family member (for example: another student or parent)

*My student may only leave campus with the following person(s): __________________________________________________________________ or__________________________________________________________________ or__________________________________________________________________

*If you check this box, your student will wait in the check-out room until a person, listed above, arrives and provides photo ID to verify a match with your request.

WSU TRI-CITIES GEAR UP STUDENTS ONLY: My student will be taken to and from camp with transportation authorized and coordinated by GEAR UP. See site managers for instructions.

The above information is correct and accurately reflects the student to whom it pertains. The person described has permission to participate in all program activities except as set forth above by me and/or an examining physician. I understand this form will be shared on a “need to know” basis with WSU staff. I give permission to copy this form for those purposes. I voluntarily sign this authorization in consideration for permission for my student to participate in the WSU Tri-Cities Cougar Discovery pre-college summer program. I have read it, and I understand its content and significance.

(BOTH SIGNATURES ARE REQUIRED)

Signature of Parent/Guardian Date

Signature of Witness NOTE: A Witness need not be a notary or have an official position. They may be a spouse, friend, or co-worker.

Date

Code of Conduct: Compliance with this Code of Conduct is required of all program participants. Failure to comply, at the discretion of WSU Tri-Cities, may result in dismissal from the Cougar Discovery pre-college summer program. In the event of violation, the Student’s parent or guardian may be contacted. Program participants shall be respectful of the WSU Tri-Cities community, which includes people with diverse backgrounds and beliefs. Conduct that is disrespectful or demeaning to others, including but not limited to verbal or physical harassment, will not be tolerated.

The following actions are prohibited during any part of the program:

(1) Failure to adhere to any Student Conduct and Accountability code. Visit tricities.wsu.edu/conduct (2) Possession, use, distribution, or being in the presence of alcohol or illegal drugs (3) Misuse of prescription drugs (4) Use of tobacco products (5) Possession or use of weapons (6) Disorderly conduct, including but not limited to verbal or physical harassment, misuse/damage/theft or University property and equipment,

use of video or audio recording where privacy is expected, and interaction of a sexual nature or sexually suggestive manner with any other person

(7) Use of offensive language such as swearing (8) Traveling outside of the designated campus area boundary without prior permission or supervision from Cougar Discovery staff

Computers and Mobile Electronic Devices Students are not encouraged to bring any personal electronic devices other than a smartphone to Cougar Discovery. During program sessions and activities, distracting and inappropriate use of any personal electronic devices which may include, but not limited to, cell phones/smartphones, laptops, tablets, cameras, and MP3 players will result in confiscation of the device available for claiming at the end of the day. Students will be informed of which workshops encourage the use of a smartphone, in which case specific instructions will be given. WSU Tri-Cities will not be responsible for lost, stolen, or damaged personal items.

Dress Code & Cancellation or “No Show” Policy Students are required to follow their school district dress code policy while attending Cougar Discovery. Most workshops and activities will take place indoors, however, some will require students to walk to and from different buildings. Comfortable walking shoes are encouraged.

In the event that requires you to cancel your attendance to Cougar Discovery, students must notify the Professional Development & Community Education (PDCE) office by May 26, 2017. Contact information is at the bottom of page five of this registration packet.

Completing Registration Please do not email or scan any forms attached to this registration.

GEAR UP Students: See the GEAR UP site manager at your school for instructions.

Mail your completed registration form with a check (made payable to WSU Tri-Cities PDCE) to:

WSU Tri-Cities PDCE 2710 Crimson Way Richland, WA 99354

Space is limited and this registration form is required to have on file with the WSU Tri-Cities PDCE office prior to attending.

I, __________________________________________________________ (student), agree to comply with the above expectations. I understand that failure to comply may result in being removed from Cougar Discovery with no refund allowed.

(BOTH SIGNATURES ARE REQUIRED)

Signature of Student Date

Signature of Parent/Guardian Date

CHOOSING YOUR MAJOR! *REQUIRED Students will have the opportunity to choose a “Major” and attend a dynamic session for the first three days taught by experts in that field of study. STUDENTS: Please select your top three choices of the “Major” you would like to attend. Select your first choice by placing a number 1 on the left column beside the name of “Major”. Place a 2 and 3 in the same manner for your second and third choices respectively. If your first choice is not available, you will be placed in your second choice. Looking for more information about each major? Visit the websites below corresponding with each program. ________ Engineering (Civil, Electrical, or Mechanical) tricities.wsu.edu/engineering ________ Computer Science tricities.wsu.edu/computerscience ________ Business Administration & Hospitality Business Management tricities.wsu.edu/business ________ Nursing tricities.wsu.edu/nursing ________ Education tricities.wsu.edu/education ________ Digital Technology & Culture tricities.wsu.edu/dtc ________ Humanities, Social Sciences, & Psychology tricities.wsu.edu/cas/undergraduate/humanities tricities.wsu.edu/cas/undergraduate/socialsciences tricities.wsu.edu/cas/undergraduate/psychology ________ Earth & Environmental Science tricities.wsu.edu/cas/undergraduate/environmental-science

CAREER EXPLORATION *REQUIRED Students will also have the opportunity to explore different careers during the Career Exploration sessions. Industry professionals, retired executives, and entrepreneurs from the local region will be invited to present and offer unique insights on their profession. STUDENTS: Based on the majors you selected above, please indicate below which career(s) interest you the most. For example, if you selected Business Administration as your first choice you can specify marketing, accounting, finance, etc. The careers you write-in below will help us determine which presenters to invite to campus during Career Exploration.

_____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________

For more information, questions, or concerns, please feel free to contact us!

WSU Tri-Cities PDCE Phone: (509) 372-7174 2710 Crimson Way Email: [email protected] Richland, WA 99354 Website: tricities.wsu.edu/summer/cougar-discovery

Unsure about which major is right for you?

Visit

wsutricities.mymajors.com/quiz

Complete the quiz!

RELEASE AND ASSUMPTION OF RISK For Parent or Guardian Claims of Participants Under 18 Years of Age

Name of Minor Child: _____________________________________________________

Parent or Guardian Consent

I am the parent or guardian of the child, a minor under the age of eighteen (18) legally incompetent to contract, whose name is set forth above. I certify that I am authorized to make decisions on that person’s behalf. I understand that there are risks in participating in the educational activities associated with Cougar Discovery pre-college summer program at Washington State University (WSU) Tri-Cities. In consideration for and as a condition of the above listed student being allowed to participate in this voluntary activity, I agree to take full responsibility for any and all risks that exist including the risk of death or injury to my student or loss or damage to my property. I understand that there may be risks that WSU cannot predict or foresee, and I also assume full responsibility for those risks. Risks in participating in the Cougar Discovery activities which may be conducted indoors or outdoors include, but are not limited to, serious neck and spinal injuries which may result in complete or partial paralysis and/or brain damage; serious injury to virtually all bones, joints, ligaments, muscles, tendons, and other aspects of the muscular skeletal system; serious injury or impairment to other aspects of the child’s body, general health, and well-being, and/or death. I also recognize that there are both foreseeable and unforeseeable risks of injury or death that may occur that WSU cannot specifically anticipate and list here.

Parent or Guardian’s Release of Claims and Liability I am responsible for and allow the person whose name is set forth above to participate in Cougar Discovery on WSU property. I personally and voluntarily consent to the involvement of the person whose name is set forth above. I release program sponsors individually and in their roles as employees or agents of WSU, their heirs and assigns; the state of Washington; the Regents of WSU; WSU; any subdivision or unit of WSU, its officers, employees, and agents, as well as their heirs or assigns; from any claims I may have by virtue of my role as parent or guardian and from all liability derived from my status as parent or guardian. This includes all liability, claims, costs, expenses, injuries and/or losses which I may sustain, derived from my role as parent or guardian, as a result of the participation of the above named child in the above event.

I have carefully read this document, understand its contents and am fully informed about this program and circumstances. I am aware that this document is a contract with WSU and program sponsors. I sign it freely and voluntarily.

Signature of Parent/Guardian Name of Parent/Guardian (printed) Date

Signature of Witness Name of Witness (printed) Date

NOTE: A Witness need not be a notary or have an official position. They may be a spouse, friend, or co-worker.

2017 cougar discovery student information packet · title: microsoft word - 2017 cougar discovery...

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