1. science
2. engineering

CEDO
2015 SUMMER ENGINEERING ACADEMY
SEA ENROLLMENT FORMS
THIS PACKET CONTAINS FORMS THAT ARE BOTH UNIVERSITY AND PROGRAM SPECIFIC. PLEASE
BE SURE TO COMPLETE AND SUBMIT ALL DOCUMENTS IN THE PACKET.
The following items must be returned by May 27, 2015:
SEA Forms
1.
2.
3.
4.
5.
SEA Participant Conduct Policy
Transportation Information Form
Transportation Authorization Form
Ideation Flexibilty Study Consent Form
Program Fee and Supply Information Sheet: Cashier's check or money
order (payable to "University of Michigan/CEDO") in the amount indicated
on your acceptance letter.
UM Forms
1.
2.
3.
4.
5.
6.
7.
8.
Participant Conduct Fom
Participant Agreement & Waiver Form
Medical Authorization To Treat Form
Over-The-Counter Medication Authorization Form
Self Administration of Prescription Medication Form
Pick Up Authorization Form
Media, Photo & Video Release Form
Housing Agreement Form
Please have these forms completed and returned by May 27, 2015 to:
Summer Engineering Academy
Center for Engineering Diversity and Outreach
University of Michigan, College of Engineering
1108 LEC, 1221 Beal Ave
Ann Arbor, MI 48109-2102
734.647.7120 (office)
[email protected]
2015 Enrollment Forms
CEDO
2015 SUMMER ENGINEERING ACADEMY
SEA PARTICIPANT CONDUCT POLICY
SEA takes the following position in order to provide a safe and healthy environment for all program participants
and staff members. These non-negotiable items reflect our concern for the physical and emotional well being of
program participants:
1. The possession, use and/or consumption of alcohol, illegal drugs, fireworks, explosives or weapons are
prohibited and cause for immediate dismissal from the program.
2. The SEA will not tolerate any form of physical or verbal abuse on the part of program members. This
includes such actions as the use of profanity, hitting, punching, kicking, shoving, and spitting or unreasonable
teasing.
3. The SEA will not tolerate any form of sexually abusive behavior such as inappropriate touching. Any such
actions will be cause for dismissal of individual offenders.
Failure to comply with any of the above non-negotiable items (#1, 2 and 3) will be cause for immediate dismissal
from the program and possible legal consequences. The offender(s) will return home immediately at their own
expense.
As a participant, you represent your family, school and community. Please remember this and conduct yourself
accordingly. Continued participation in the SEA is dependent upon exemplary behavior and demonstrated
commitment to hard work in the program.
I have read and understand the above statement and will adhere to all of the policies outlined above.
Parent/Guardian Signature
Date
Participant Signature
Date
Please have these forms completed and returned by May 27, 2015 to:
Summer Engineering Academy
Center for Engineering Diversity and Outreach
University of Michigan, College of Engineering
1108 LEC, 1221 Beal Ave
Ann Arbor, MI 48109-2102
734.647.7120 (office)
[email protected]
2015 Enrollment Forms
CEDO
2015 SUMMER ENGINEERING ACADEMY
TRANSPORTATION INFORMATION
Students/Parents are responsible for the participant’s transportation to and from the Ann Arbor, MI area. The
Summer Engineering Academy (SEA) provides transportation for students arriving by plane, bus or train to the
University of Michigan campus (from locations listed below). Please indicate your child’s mode of transportation,
travel date and times so we can make proper arrangements for your child’s pickup.
Student’s Name:__________________________________________
Please indicate how your child will be traveling to/from Ann Arbor:
ˆ Detroit Metro Airport (DTW)
Arrival Information
Airline:
Flight#:
Date:
Time:
Departure Information
Airline:
Flight#:
Date:
Time:
ˆ Ann Arbor Train Station
Arrival Information
Service/Trip#:
Date:
Time:
Departure Information
Service/Trip#:
Date:
Time:
ˆ Ann Arbor Bus Depot
Arrival Information
Bus Line:
Ticket/Order#:
Date:
Time:
Departure Information
Bus Line:
Ticket/Order#:
Date:
Time:
ˆ Car with Parents
Please have these forms completed and returned by May 27, 2015 to:
Summer Engineering Academy
Center for Engineering Diversity and Outreach
University of Michigan, College of Engineering
1108 LEC, 1221 Beal Ave
Ann Arbor, MI 48109-2102
734.647.7120 (office)
[email protected]
2015 Enrollment Forms
CEDO
2015 SUMMER ENGINEERING ACADEMY
TRANSPORTATION AUTHORIZATION
I understand that my child/children will move from the North Campus to the Central Campus and to various
local sites using the University of Michigan bus system or Summer Engineering Academy(SEA) university
vehicles. My child will be chaperoned while on the bus. I agree to allow my child to use the University bus system
and the SEA university vehicles for transport.
By signing below I, _________________________________________________ agree to the above condition.
Parent/Guardian Signature: ________________________________________________ Date: ____________
T-SHIRT INFORMATION:
Please indicate participant's T-shirt size (all sizes are adult sizes).
Small
Medium
Large
X-Large
2X-Large
Please have these forms completed and returned by May 27, 2015 to:
Summer Engineering Academy
Center for Engineering Diversity and Outreach
University of Michigan, College of Engineering
1108 LEC, 1221 Beal Ave
Ann Arbor, MI 48109-2102
734.647.7120 (office)
[email protected]
2015 Enrollment Forms
CEDO
2015 SUMMER ENGINEERING ACADEMY
PROGRAM FEE AND SUPPLY INFORMATION SHEET
As you know, almost all program costs for the Summer Engineering Academy (SEA) are provided for
participants through University funding, grants, and corporate contributions. These costs estimated at $1800 per
student include room charges in the residence hall, food service contract, instructional costs (including staff and
course materials), and all related cultural and enrichment activities. The generous funding received for this
program allows students to participate for a minimal program fee.
We ask that this fee, as stated on your acceptance letter, be submitted in the form of a cashier’s check or
money order (payable to “University of Michigan/CEDO). Please note that we are unable to accept
personal checks for this program deposit. The program deposit is due, along with the enclosed forms, by date
indicated on acceptance letter.
We ask that all SEA students bring their own personal classroom supplies. The supplies that will be most useful
are as follows:
1.
2.
3.
4.
512 MB Flash Drive
Pens, pencils, highlighter markers
Scientific Calculator
Drawstring Bag/ Small Backpack
Note: Students do NOT need to bring laptop computers; participants will have full access to computer labs during class
time/homework time.
HOUSING INFORMATION
1. Participants will be housed in Bursley Hall on North Campus. The enclosed map shows the location of Bursley Hall and also
shows how to get there from the freeways.
2. Participants will be housed in double rooms. Members of our staff will be occupying rooms in the same area. Unfortunately,
the rooms are not air-conditioned; therefore, you may wish to bring a small fan.
3. The rooms are equipped with desks, chairs, beds, lamps, dressers.
Please have these forms completed and returned by May 27, 2015 to:
Summer Engineering Academy
Center for Engineering Diversity and Outreach
University of Michigan, College of Engineering
1108 LEC, 1221 Beal Ave
Ann Arbor, MI 48109-2102
734.647.7120 (office)
[email protected]
2015 Enrollment Forms
CEDO
2015 SUMMER ENGINEERING ACADEMY
4. Please bring the items on the following list for your use in the residence hall:
Sheets & Pillow
Towels
Shower Shoes/Shower Cap
Face Cloths/Loofahs
Soap
Bath Robe
Personal Toiletries
Alarm Clock
Swimming/Athletic Gear
Sheets, pillows, pillowcases, and blankets are NOT provided by the residence hall. Coin operated laundry facilities are available
in the residence hall. It costs approximately $1.25 to wash one load and $1.00 to dry one load.
5. Individual phones in each residence hall room will be available for incoming and local calls. Long distance service will not be
available. Long distance calls require a calling card or calls made "collect".
6. Each student will share a telephone with their roommate (the phone number will be known once they check in).
A. If the student cannot be reached by phone, a message can be left at the SEA Office (734) 647-7120.
B. Mail can be sent to:
Participant's Name
University of Michigan
Room #___ (received at check-in)
Bursley Hall
1931 Duffield
Ann Arbor, MI 48109-2116
7. Move-in procedures for the residence hall will occur (4:00 PM to 6:00 PM) following the opening ceremony. The SEA
residential facilitators will be available to help participants.
8. Participants will be required to vacate the rooms by 5:00 PM on the last day of your program. The residential facilitators will
assist with moving arrangements.
9. The residence hall meal contract provides breakfast, lunch and dinner, Monday through Friday. On Saturdays, only one meal
(brunch) is served at 11:30 AM. On Sundays, two meals are served, brunch and dinner. Students should bring up to $40 for
snacks/one dinner and any money they may want for shopping.
10. Meal cards will be issued during registration. Lost meal cards will be replaced at the participant's expense.
11. ACADEMY PARTICIPANTS MAY NOT BRING: Televisions, DVD players, portable video games or other stereo
equipment while participating in the program.
Please have these forms completed and returned by May 27, 2015 to:
Summer Engineering Academy
Center for Engineering Diversity and Outreach
University of Michigan, College of Engineering
1108 LEC, 1221 Beal Ave
Ann Arbor, MI 48109-2102
734.647.7120 (office)
[email protected]
2015 Enrollment Forms
CEDO
2015 SUMMER ENGINEERING ACADEMY
DIRECTIONS TO BURSLEY RESIDENCE HALL
1931 Duffield St., Ann Arbor, MI 48109-2080
NORTH CAMPUS
From Jeffries Fwy / M-14:
Take the Jeffries Freeway (west) past Interstate 275
(here the Jeffries Freeway becomes M-14). Follow
M-14, remaining in the left lane to US 23 south (sign
reads to Toledo, NOT Ann Arbor). Take exit 41
(Plymouth Road). Follow Plymouth Road west to the
fourth stop light (Murfin Ave). Turn left on Murfin.
Travel 1 block, turn right on Hubbard and park in the
large lot across the street from Bursley Hall.
From US-23:
Take exit 41 (Plymouth Road). Follow Plymouth
Road west to the fourth stop light (Murfin Ave). Turn
left on Murfin. Travel 1 block, turn right on Hubbard
and park in the large lot across the street from Bursley
Hall.
from 1-94:
Take US-23 North to Exit 41 (Plymouth Road) (3rd
exit). Follow Plymouth Road west to the fourth stop
light (Murfin Ave). Turn left on Murfin. Travel 1
block, turn right on Hubbard and park in the large lot
across the street from Bursley Hall.
From 1-96:
Take I-96 east to US-23 south. Follow US-23 to M14 east towards Plymouth/Toledo, NOT Ann Arbor
(you will be veering to your left). Follow M-14 to US
23 South (sign reads Toledo NOT Plymouth). From
US-23 take Exit 41 (Plymouth Road). Follow
Plymouth Road west to the fourth stop light (Murfin
Ave). Turn left on Murfin. Travel 1 block, turn right
on Hubbard and park in the large lot across the street
from Bursley Hall.
Please have these forms completed and returned by May 27, 2015 to:
Summer Engineering Academy
Center for Engineering Diversity and Outreach
University of Michigan, College of Engineering
1108 LEC, 1221 Beal Ave
Ann Arbor, MI 48109-2102
734.647.7120 (office)
[email protected]
2015 Enrollment Forms
CEDO
2015 SUMMER ENGINEERING ACADEMY
Locations for opening and closing programs will be sent to each participant at a later date.
Please have these forms completed and returned by May 27, 2015 to:
Summer Engineering Academy
Center for Engineering Diversity and Outreach
University of Michigan, College of Engineering
1108 LEC, 1221 Beal Ave
Ann Arbor, MI 48109-2102
734.647.7120 (office)
[email protected]
2015 Enrollment Forms
C H I LD RE N ON CAM PU S
PA RT I CI PAN T C O N D U C T A G R E E M ENT
Program/Camp Name:
(hereafter “Program”) Date(s):Time(s):
Participant Name:
(hereafter “Participant”) Parent/Guardian Name:
Program has established rules and standards of conduct for all Participants. It is the responsibility of the Parent/Legal Guardian and the Participant
to review the Program rules and standards of conduct. Dismissed Participants are not eligible for a refund of any fees or expenses. The Parent/Legal
Guardian is responsible for all costs associated with removing the Participant from the Program due to his/her misconduct, including but not limited
to transportation costs to return the Participant home.
PARTICIPANT AGREEMENT
I understand that as a condition for participating in the Program that I must comply with the Program’s rules and standards of conduct and follow
all reasonable direction of the Program Staff. Failure to comply with the Program’s rules and standards of conduct or failure to comply with the
reasonable direction of Program Staff may result my being dismissed from the Program.
Participant’s Signature:
Date:
PARENT/LEGAL GUARDIAN AGREEMENT
I understand that my child will be subject to the rules and standards of conduct of the Program and the University of Michigan. I further understand
that my child’s violation of the rules and standards of conduct or failure to comply with the reasonable direction of Program Staff may result in my
child’s dismissal from the Program. I accept responsibility for all costs associated with removing my child from the Program, including but not limited
to transportation costs to return the Participant home.
Parent/Legal Guardian’s Signature:
Date:
C H I LD RE N ON CAM PU S
PA RT I CI PAT I O N A G R E E M E N T A ND WA IV ER FO R M
PROGRAM/CAMP INFORMATION
Parents and legal guardians are responsible for carefully reviewing all program materials and for selecting programs that are appropriate for their
child. Information regarding University of Michigan sponsored programming for children and teens is available at childrenoncampus.umich.edu.
Program/Camp Name: (hereafter “Program”)
Date(s):
Location: PARTICIPANT INFORMATION
Name of Participant: (hereafter “Participant”)
Address:
City:
State:Zip:
Phone Number:
Date of Birth:
Gender:
Male
Female
PARTICIPATION AGREEMENT AND WAIVER
I understand that my child’s participation in the Program is voluntary and that as I condition of my child’s participation, I agree to comply with all
Program requirements including, but not limited to: (a) accurately completing all registration forms in a timely manner, (b) ensuring that my child is
aware of the Program’s standards of conduct; (c) and immediately notifying the Program Administrator of any concerns related to the health, safety or
security of my child, other participants, or Program staff.
I understand that as part of my child’s participation in the Program that there are dangers, hazards and inherent risks to which my child may be
exposed, including the risk of serious physical injury, temporary or permanent disability, and death, as well as economic and property loss. I further
realize that participating in the Program may involve risks and dangers, both known and unknown, and I have chosen to allow my child to take part
in the Program. Therefore, I, and on behalf of my child, have determined that it is reasonable to accept all risk of injury, loss of life or damage to
property arising out of training, preparing, participating, and traveling to or from the Program and I do voluntarily accept and assume those risks.
I release the University of Michigan, its Board of Regents, Administration, Faculty, Staff, Graduate Students, and all other officers, directors,
employees, volunteers and agents from any claims or liability arising from my child’s participation in the Program, provided that such claim is not due
to the gross and sole negligence of the released parties.
In the event of an accident or serious illness, I authorize representatives of the University to obtain medical treatment for my child. I hold harmless
and agree to indemnify the University from any claims, causes of action, damages and/or liabilities, arising out of or resulting from said medical
treatment. I further agree to accept full responsibility for any and all expenses, including medical expenses that may derive from any injuries to my
Child that may occur during his/her participation in the Activity.
I also agree to indemnify the University and all of its employees and agents from any financial obligations or liabilities that my child may cause while
participating in the Program, including attorney’s fees and court costs resulting from his/her misconduct, errors, or omissions.
I acknowledge that University employees have undergone criminal background checks, but other participants of the event may not have undergone
background check screening. As such, the University makes no assertions or assurances with respect to other participants.
This Agreement is governed by and construed under the laws of the State of Michigan without regard for principles of choice of law. Any claims,
demands, or actions arising under this Agreement must be brought in the Michigan Court of Claims or a court with applicable subject matter
jurisdiction sitting in the state of Michigan and I consent to the jurisdiction of a Michigan court with appropriate subject matter jurisdiction.
I agree that the terms and conditions of this Agreement are binding on my representatives, heirs and assigns.
Parent/Guardian Name Parent/Guardian Signature:
Date:
C H I LD RE N ON CAM PU S
MED I CAL AUTH O R I Z AT I O N T O T REAT
UNIVERSITY SPONSORED PROGRAMS
The University of Michigan requests this information so that the Program staff can properly plan to meet the needs of each participant and, in case
of emergency, that we have accurate information to provide and/or seek appropriate treatment for Participant. You are responsible for providing
accurate and complete information.
All Participants must have up-to-date immunizations in order to participate in any university-sponsored program.
Program/Camp Name:
(hereafter “Program”) Date(s):
Location: GENERAL INFORMATION
Participant Name
(hereafter “Participant”) Street Address
City
State
Zip Home Phone
Date of Birth
/
/
Gender
Male
Female INSURANCE INFORMATION
Do you have health/accident insurance?
YES
NO
If yes,
Company Name / Address
Policy # PLEASE ATTACH A COPY OF THE FRONT AND BACK OF YOUR INSURANCE CARD WITH THIS FORM
The University of Michigan does not offer any form of health, liability or other types of insurance for the participant while participating in the
Program.
MEDICAL INFORMATION
It is recommended that you consult with your child’s physician before allowing your child to participate in this Program. If you answer yes to any of
the following questions, please explain as indicated. Use back and/or additional paper if needed.
Physician’s Name
Phone Number Physician’s Address
Date of most recent tetanus toxoid immunization (DTaP, TD) For the following, provide response and explain as appropriate:
Does participant have any limiting medical conditions that you or your doctor feel may limit Program participation? YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
If yes, identify and explain:
Is participant currently taking medication that may interfere with ability to safely participate in Program?
If yes, identify and explain:
Is the participant taking any medications that must be administered during the Program?
If yes, identify and explain:
Does participant have a history of allergies or reactions to medications, foods, insect stings, or plants?
If yes, identify and explain:
Does participant have a history of, or currently suffer from, medical condition(s) about which we need to be aware?
If yes, identify and explain:
Does the participant need any accommodations to safely participate in the Program?
If yes, identify and explain:
If Participant has any other medical condition or special needs that you think is important for Program staff to know about, please include that
information here.
Other Information:
AUTHORIZATION FOR MEDICAL CARE
To the best of my knowledge, my child/participant is capable of participating safely in the Program and that any activity restrictions, allergies,
medications are listed on this form.
I give permission to Program staff to provide routine first aid care and in the event of serious illness or injury, I give Program staff permission to seek
and authorize emergency medical treatment. I hold harmless and agree to indemnify the Program and the University of Michigan from any claims,
causes of action, damages and/or liabilities arising out of or resulting from said medical treatment. I further agree to accept full responsibility for
any and all expenses, including medical expenses, that may derive from any injuries to my child that may occur during his/her participation in this
Program.
I understand and acknowledge that my failure to disclose relevant information may result in harm to Participant and/or others during this Program. By
signing my name, I represent that I have provided all materials and important information to the Program pertaining to Participant’s medical, mental
and physical condition and that it is accurate and complete. I agree to notify the Program of any changes in my mental, physical or medical condition
before the Program begins.
Parent/Legal Guardian Name:
Signature:
Work Phone:
Cell Phone:
Date
Parent/Legal Guardian Name:
Signature:
Work Phone:
Cell Phone:
Date
EMERGENCY CONTACT INFORMATION
List at least two and up to four individuals who may be contacted in case of emergency involving your child. Each person listed should be reachable
by telephone and able to make decisions on behalf of your child if a parent and legal guardian cannot be reached. If necessary, an emergency
contact should be able to come to the Program site and pick up your child.
Emergency Contact #1 Name
Home Phone #
Work Phone #
Cell Phone #
Relation
Emergency Contact #2 Name
Home Phone #
Work Phone #
Cell Phone #
Relation
Emergency Contact #3 Name
Home Phone #
Work Phone #
Cell Phone #
Relation
Emergency Contact #4 Name
Home Phone #
Work Phone #
Cell Phone #
Relation
C H I LD RE N ON CAM PU S
OV ER -T HE -CO U N T E R M E D I C AT I ON A U TH O R IZATIO N FO R M
Program/Camp Name:
(hereafter “Program”) Date(s):
Location: PARTICIPANT INFORMATION
Participant Name
(hereafter “Participant”) Participants Age:
Select Over-the-Counter (OTC) medication may be administered, if we have written permission from the Participant’s parent or guardian.
Note: Unless we have parental authorization, we will not administer ANY medications or make OTC medications available to
participants unless necessary as part of general first-aid treatment.
I give permission for the Program staff to administer the following medications to my Participant consistent with medication directions, if the need
arises. Check all that apply.
Actifed or Sudafed as directed for nasal
congestion and allergy relief
Benadryl for swelling, hives, allergic
reaction
Bug repellant
Calamine lotion for bug bites and poison ivy
Hydrocortizone cream for mild skin
irritations, poison ivy and insect bites
Ibuprofen
Kaopectate or Immodium for diarrhea
Medicated lip ointment for dry, chapped
lips, lip blisters or canker sores
Medicated powder for skin irritation
Swimmer’s ear drops
Micatin or anti-fungus treatment for
athlete’s foot
Throat lozenges and or spray for sore throat
Milk of Magnesia for constipation
Ointments for minor would care, such as an
antiseptic, anti-itch, anti-sting, antibiotic or
sunburn cream
Pepto Bismol or Mylanta for upset stomach
or nausea
Rolaids or Tums for acid reflux, heartburn or
indigestion
Tylenol/Acetaminophen
Visine or other eye drops for minor eye
irritation
Other (list any other approved over-thecounter drugs)
Do not provide Participant with any OTC
that contains the following:
Sunscreen
I understand that these over-the-counter medications are not necessarily kept on-hand and available to be administered immediately. Program staff
will use generic equivalents when available for the name-brand over-the-counter medications listed above. I understand that the administration of
OTC medication will not be done under the supervision of medical personnel.
Any condition which is associated with fever, significant inflammation, and/or does not respond to the above outlined OTC treatment will be
followed-up by a consultation with the Participant’s parent/guardian. Parent/guardian will be contacted if any conditions develop requiring treatment
with any of the above over-the-counter medications that are not checked.
I authorize the administration of checked OTC medications to my child as indicated above and general first aid treatment.
Parent/Guardian Name:
Parent/Guardian Signature:
Date:
C H I LD RE N ON CAM PU S
SELF -ADM I N I S T R AT I O N O F P R E S C R IP TIO N M ED IC ATIO N FO R M
PROGRAM/CAMP INFORMATION
Program/Camp Name: (hereafter “Program”)
Location:Date(s):
PARTICIPANT INFORMATION
Participant’s Name: (hereafter “Participant”)
Participant’s Age:
This form must be completed fully in order for participants to self-administer required medication. State law requires that a written emergency care
plan must be on file that is “prepared by a licensed physician in collaboration with the minor child and the minor child’s legal parent or guardian, and
that is updated as necessary for changing circumstances.” A new medication administration form must be completed for each Program attended by
the participant, for each medication, each time there is a change in dosage or time of administration of a medication and/or at three month intervals.
Self-medication requires licensed health care authorization and signature, and parent signature.
My child does not need to take any prescription medication while at the Program.
My child will need to take prescription medication while at the Program.
My child needs to keep this medication with him/her at all times for emergency care.
All prescription medications, including medications for conditions such as food, drug or insect allergies; diabetes; asthma; or epilepsy may be brought
to the Program under the condition that the participant can self-manage care and delivery of medication with written authorization to do so by a
licensed health care provider. Prescription medication must be in its original container labeled by the pharmacist or prescriber. The label must include
the name, address and phone number for pharmacist or prescriber. Containers must hold only standard dose vials or the amount required for the time
the participant will be attending the Program.
PRESCRIBER AUTHORIZATION FOR SELF-ADMINISTRATION OF PRESCRIPTION MEDICATION
Medication Name:
Dose:
Condition for which medication is being administered: Specific Directions (e.g., on empty stomach/with water, etc.):
Time/Frequency of administration:
If as-needed, for what symptoms?
Relevant side effects:
Medication shall be administered from:
(date)
to (date)
Special Storage Requirements:
Is the participant capable of self-managed care
YES
NO
Prescriber’s Name/Title:
Address:
Telephone:
Fax:Email:
I hereby affirm that this individual has been instructed in the proper self-administration of the prescribed medication(s).
Prescriber’s Signature:
Date:
I authorize and recommend self-medication by my child for the above medication. I also affirm that he/she has been instructed in the proper
self-administration of the prescribed medication by his/her attending physician or other health care provider. I indemnify and hold harmless the
Program Staff, the University of Michigan, and the University’s employees and agents against any claims that may arise relating to my child’s selfadministration of the prescribed medication(s).
Parent/Guardian Name Parent/Guardian Signature:
Date:
C H I LD RE N ON CAM PU S
PI CK UP AUT H O R I Z AT I O N
Program Name:
Date(s):
(hereafter “Program”)
Time(s):
Participant Name:
(hereafter “Participant”)
Parent/Legal Guardian Name:
Please fill out either Section I or II.
SECTION I
Please list any individual who is authorized to pick up your child, including yourself. Each authorized person must be at least 16 years of age. The
above-named Participant will not be permitted to leave the Program with anyone who is not listed below. Authorized individuals must pick up
children in person and may be requested to show identification to Program staff when picking up a Participant. Participants will not be released to
persons who fail to provide acceptable identification upon request.
I authorize the following responsible person to pick up my child from the aforementioned Program activities:
AUTHORIZED PERSON
PHONE NUMBER
RELATIONSHIP TO CHILD
The following individuals are not permitted to pick up my child:
UNAUTHORIZED PERSON
BRIEF PHYSICAL DESCRIPTION
RELATIONSHIP TO CHILD
Parent/Guardian Signature: Date:
Parent/Guardian Phone number:
SECTION II
My son/daughter is at least 16 years of age and will responsible for his/her own transportation to and from Program. My son/daughter may sign
him/herself in at the start of Program activities and sign him/herself out at the end of Program activities.
Parent/Guardian Signature: Date:
C H I LD RE N ON CAM PU S
MED I A, PHOTO & V I D E O R E L E A S E FO R M
Program/Camp:
Date(s):
Time(s):
Location:
Please check one box:
Yes - Media, Photo and Video Authorization
I understand that during the course of my child’s participation in the above-referenced activity, that the Program, and those acting with the
Program’s permission or authority, may capture my child’s name, likeness, image, or voice in photographic, audio, video, digital or other
recording forms (“Recordings”). I give my permission for the Program to use those recordings or works produced by my child (e.g., art work)
for promotional, commercial, informational, and educational purposes in any and all media (including the Internet) now existing or hereafter
devised, for any purpose consistent with the Program’s mission. I understand that I will not have an opportunity to review or approve uses of
the Recordings or Works.
I recognize that the Program, through the Board of Regents of the University of Michigan (“University”), holds the copyright in all Recordings. I
understand that neither my child nor I will receive payment or any other compensation for the taking or use of any Recordings or Works created
as a result of my child’s participation in the Program.
I release, indemnify and hold harmless the University from and against all liability, actions, debts, claims and demands of every kind whatsoever
to the taking or use of the Recordings or Works of my child.
No-Media, Photo or Video Authorization
I do not grant permission to Program to take or use my child’s name, likeness, image, or voice in any form or to use work produced by child for
any reason unless necessary for the administration of the Program while my child is participating in the Program.
Participant’s Name:
Parent/Legal Guardian’s Name:
Parent/Guardian Signature:
Date: