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Griffon Nurse Training Camp Registration
Griffon Nurse Training Camp Registration
michend
2024-04-23T15:42:19-05:00
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CAMPER INFORMATION
First Name:
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Middle Name:
Last Name:
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Address:
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Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
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Iowa
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Maryland
Massachusetts
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New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Date of Birth:
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Month
Day
Year
Sex/Gender:
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Camper T-Shirt Size:
(T-shirt size is not guaranteed. Please indicate your first and second size preferences.)
First Size Preference:
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Choose...
Adult Small
Adult Medium
Adult Large
Adult X-Large
Youth Small
Youth Medium
Youth Large
Youth X-Large
Second Size Preference:
*
Choose...
Adult Small
Adult Medium
Adult Large
Adult X-Large
Youth Small
Youth Medium
Youth Large
Youth X-Large
PARENT/LEGAL GUARDIAN INFORMATION
Name:
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Name:
Relationship:
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Relationship:
Email:
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Email:
Phone:
*
Phone:
EMERGENCY CONTACT
Name:
*
Relationship to Camper:
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Phone Number of Contact Person:
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CAMPER HEALTH HISTORY
Please provide us with information regarding Camper’s/child's health, medical and/or emotional needs. Camper information will be confidential and used to help each camper stay safe and find success.
Please list any and all known allergies. (Include descriptions of any potential reactions, EpiPen requirements and other management plans.)
Please check if Camper/child has or has had the following:
Recent injury, illness, or infection
Chronic or recurring illness
Been hospitalized
Had surgery
Frequent headaches
Head Injury
Wears glasses/contacts
Hearing Impairment
Other
Include additional information here:
*
Please tell us more about your Camper/child. This information is invaluable in helping our staff to provide exceptional care and to help each Camper/child succeed in the Griffon Nurse Training Camp.
If Camper/Child has any activity restrictions, please describe them here:
Camper/Child has the following condition(s) requiring staff knowledge and/or attention:
These things may be a source of frustration for Camper/child:
It helps Camper/child when:
Is there any other information that would be helpful in meeting the physical, mental or emotional needs of Camper/child?
MEDICATIONS
All medications (prescription or non-prescription) shall be kept in the original container and labeled with the Camper’s/Child’s name and instructions including times and amounts for dosages, and the name of the Camper’s/Child’s physician.
I authorize Griffon Nurse Training Camp staff to administer the following medication to Camper/child:
Name of Medication
Specific time(s) to be taken each day
Reason(s) for taking
Possible side effects
Dosage
Add
Remove
If Camper/child has asthma, please indicate the following:
I give Camper/child permission to carry an inhaler and self-administer as needed.
I prefer the camp staff keep Camper's/child’s inhaler and help Camper/child determine when it is needed.
CONSENT FOR ADMINISTERING OF APPROVED OVER-THE-COUNTER MEDICATIONS
I hereby give permission for Camper/child to receive any medication listed below as deemed necessary by the Camp Administrators. I have checked those medications I wish to be made available to Camper/child as needed.
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ACETAMINOPHIN (I.E. TYLENOL)
ANTACID (I.E. TUMS)
ANTI-ITCHING CREAM (I.E. HYDROCORTISONE)
ANTI-ITCHING LOTION (I.E. CALAMINE LOTION)
ANTIHISTAMINE (I.E. BENADRYL)
BUG SPRAY
IBUPROFEN (I.E. ADVIL)
STING RELIEF
SUNSCREEN
I do NOT want any of the above medication given to Camper/child at camp.
I will provide my own medication for Camper/child.
We are happy to accommodate children with disabilities and special needs. Please notify the Camp Administrator of Camper's/child’s disabilities and special needs as soon as possible but no later than the Camper’s/child’s first day in the program.
PHOTOGRAPHY
I/we, the undersigned, do hereby authorize and give to University, its employees, designees, agents, and all persons or entities for or through whom University is acting, permission and the absolute right to take, publish, use, edit, reproduce, distribute and other similar activity Camper’s/child’s likeness and/or voice regardless of the medium used, to specifically include but not limited to, photographic, video, audio, digital or other electronic medium. I/we understand that this information may be used for any lawful purpose to include artistic works, promotional or advertising efforts, publicity or recruitment and by signing this document expressly authorize such use. I agree that any reproduction of my likeness becomes the exclusive property of the University.
I/we understand and agree that I shall not be notified when any reproduction of my likeness, regardless of form, is used, nor will I/we be given the opportunity to view or approve of the reproduction prior to its publication. I/we further understand and agree that there will be no remuneration or compensation provided for any use of Camper’s/child’s likeness, and I hereby waive any rights to royalties or other compensation arising from any use of Camper’s/child's likeness by the University.
I/we release and agree to hold harmless the University, its employees, designees, agents, and all persons or entities for or through whom the University is acting, from any liability in connection of taking, storing or using any reproduction of Camper’s/child’s likeness regardless of medium. I/we have read and fully understand the terms of this photographic consent and release form.
Photography Permission
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Permission Granted
Permission Denied
CONDUCT EXPECTATIONS
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We want Griffon Nurse Training Camp to be a fun, safe and stimulating environment for everyone. In order to help us achieve this, it is important that both you and your Camper/child read and understand the Conduct Expectations and agree to following rules by signing at the bottom of this page. Please help your Camper/child understand their responsibilities for both themselves and towards others while attending camp. Thank you!
We recognize that it's not always easy for campers to make positive choices and sometimes they don’t know the right choice. For small behavior issues, Campers/children will be given reminders and a reasonable opportunity to correct their behavior before being disciplined. The University reserves the right to immediately dismiss a Camper/child for failing to follow Camp Administrator or staff directives, creating a disruptive or unsafe environment, violating Conduct Expectations, or other situations that may warrant immediately removal.
Camper will show respect to other campers and treat them as well as Camper would like to be treated.
Camper will show respect to staff and cooperate with their instructions.
Camper will not verbally abuse others by using inappropriate language, gossip, threats, teasing, exclusion or harassment.
Camper will respect the environment by refraining from littering, vandalizing, stealing or abusing equipment that does not belong to Camper.
Camper will not deliberately cause bodily harm to other campers or staff. Camper understands that kicking, punching, hitting or fighting are not acceptable forms of behavior and will not be tolerated.
Camper will respect the property of other campers and staff.
Camper will be a positive contributor and will participate in all camp programs and activities.
Camper understands that should the Camp Administration feel as though the Camper's behavior or actions may cause harm to the Camper or others, Camper may not be permitted to attend Camp for the remainder of the summer.
Drugs, alcohol, any form of tobacco, firearms, knives, or any kind of weapon, or fireworks are NOT allowed on University property.
Appropriate shoes and shirts must be worn in all campus facilities and during camp experiences.
Campers MUST be signed in and out by an approved party to be designated by the guardian.
No refunds are available to Campers who leave camp early for any reason. If an emergency arises, notify appropriate Camp staff immediately.
All medications must be in original bottle and/or container. Campers are not to share any medications, including over-the-counter medications.
Camper understands that these rules and guidelines are for the safety and the protection of myself and all campers and staff.
I agree to the Conduct Expectations.
RELEASE OF LIABILITY AGREEMENT
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ACKNOWLEDGEMENT AND ACCEPTANCE OF RISK. I/we understand that there are certain dangers, hazards and risks (foreseen and unforeseen) inherent in allowing Camper/child to attend and participate in the Griffon Nurse Training Camp (Camp) and its associated activities as operated by and/or located on the Missouri Western State University(University) campus, including, without limitation, risks related to use of equipment and facilities, personal safety (including risks of minor, serious, or mortal personal injury) and risks of property damage. Despite precautions, accidents and injuries can and will occur. I/we appreciate the character of the risk associated with the Camp and its related activities and voluntarily assume all risk of harm. I/we therefore agree to assume all of the risks and responsibilities in any way associated with Camper’s/child’s participation in the Camp.
I/we further acknowledge and agree that the University will have no responsibility for the safekeeping of any personal property left in any buildings, facilities, or elsewhere on campus, including its residence halls. I/we agree to assume full responsibility for, and risk of, property damage while attending the Camp.
[I/we am specifically aware of the dangers involved in participation in the physical activities of the Camp and all activities related to the Camp during activities, practices, and events. Further, I am aware that activities related to the Camp will involve the use of certain equipment. I/we am aware that such equipment in no way guarantees Camper’s/child’s safety from injury. Additionally, said equipment must be used in a proper manner; therefore, I/we understand Camper/child must follow any and all instructions related to the use of equipment including those instructions provided by the manufacturer, equipment personnel and Camp Administrators.]
[I/we understand that the University may exclude individuals from participating in the Camp in the event that the Camper/child appears to be suffering from a contagious illness, such as flu or COVID-19, or otherwise is a risk to the health, safety, and/or welfare of other participants or Camp staff, and that no refund of any fees will be made in such circumstances. I/we understand that the University may exclude individuals from participating in the Camp in the event that Camper/child fails to abide by the University’s health and safety protocols, disrupt, impede or interfere with the operations of the Camp, or threaten the health, safety or welfare of other participants or Camp staff, and that no refund of any fees will be made in such circumstances.
RELEASE AND HOLD HARMLESS. In consideration for the University allowing the below identified Camper/child to participate in the Camp, I/we agree to not sue the University and I/we release the University from any and all liabilities, claims, demands, actions, causes of actions, costs and expenses of any nature whatsoever arising out of any loss, damage, or injury, including death, that may be sustained by Camper/child or to any property belonging to Camper/child, arising from participation in the Camp or while upon the premises where the Camp is being conducted. I/we agree to and do hereby release, acquit, forever discharge, and covenant not to sue the University and/or its Board of Governors, administrators, officers, employees, and agents from any and all liability in connection with Camper’s/child’s participation in the Camp.
WARRANTY OF PHYSICAL FITNESS. I/we warrant that Camper/child is physically fit and in a condition that will allow Camper/child to participate fully in the Camp and its associated activities. I/we maintain medical insurance that covers Camper/child for accidents and illnesses while Camper/child is participating in this Camp and its associated activities. I/we understand the University has not made, nor will make, any investigation into above identified Camper’s/child’s physical fitness or ability to participate in the Camp, and the University is relying on my warranty of Camper’s/child’s physical condition. I /we assume full responsibility for the payment of medical expenses not covered by insurance which may be incurred as a result of participation in the Camp.
EMERGENCY MEDICAL AUTHORIZATION. I/we hereby authorize any medical treatment deemed necessary in the event of any injury while Camper/child is participating in the Camp and its associated activities. I/we grant the University permission to authorize emergency medical treatment as it deems appropriate, and agree that such action by the University shall be subject to the terms of this Release of Liability Agreement. I/we understand and agree that the University assumes no responsibility for any injury or damage that might arise out of or in connection with such authorized emergency medical treatment. I/we have appropriate insurance or, in its absence, I/we agree to pay all costs of medical services and medical transport as may be incurred on Participant’s/my child’s behalf.
INTENT. It is the express intent that this Release of Liability Agreement shall bind me/we, my spouse (if any), the members of Camper’s/child’s family, estate, heirs, administrators, assigns, and personal representatives. I/we agree that this Release of Liability Agreement and any claim arising from Camper/child’s participation in the Camp shall be construed in accordance with the laws of the State of Missouri, without regard to its conflict of laws provision. The terms of this Release of Liability Agreement shall be severable, such that if a court of competent jurisdiction holds any term to be illegal or unenforceable, the validity of the remaining portions of shall not be affected thereby. This shall serve as a release and assumption of risk by me and shall be binding of my heirs or anyone entitled to act on my behalf or on behalf of Camper/child.
In signing this Release of Liability Agreement, I hereby acknowledge and represent that I have read the foregoing Release of Liability Agreement, that I understand and agree to abide by its content and terms, and that I understand that such terms are contractual and sign it voluntarily. I have carefully read this agreement and fully understand its content.
I agree to the Release of Liability Agreement.
Signature:
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REGISTRATION
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