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VSA 2015 Information
WELCOME INFORMATION CHECKLIST FOR 2015
To Vanderbilt Summer Academy Students and Families:
We have provided this checklist to aid you in completing and returning your VSA welcome documents. Receipt of these
documents is required for participation in VSA. Please take a moment to verify the items listed below are included in this
Welcome Packet. Additional copies of these forms may be downloaded at:
http://pty.vanderbilt.edu/students/vsa/admitted/
The following items should be returned AS SOON AS POSSIBLE, but no later than
April 10, 2015 for Sessions II & III; May 8, 2015 for Session I:
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1. A check for any remaining tuition balance, if applicable
2. Permission & Release (2 pages)
3. Authorization to Consent to Treatment of a Minor
4. Physician’s Statement of General Health
5. Mental Health Professional’s Statement of General Emotional Health
6. Health History & Front & Back Copy of Student’s Health Insurance Card (6 pages)
7. Student & Parent Agreement of Policies
8. Media & Data Release
9. Transportation Information, w/check for airport transportation, if applicable
10. Areté Options & Selections
11. Student Photo
Using the enclosed envelope, please return items 1 through 11 from above to:
Vanderbilt Programs for Talented Youth
Peabody #506
230 Appleton Place
Nashville, Tennessee 37203-5721
ALL ITEMS DUE TO VANDERBILT PTY NO LATER THAN
SESSIONS II & III
SESSION I
APRIL 10, 2015
MAY 8, 2015
Have questions? Please feel free to contact us:
Phone: (615) 322-8261
Email: [email protected]
PERMISSION & RELEASE
Student Name:__________________________________________________________________
My child, the above-named student, desires to participate in the Vanderbilt Summer Academy
(hereinafter VSA). I voluntarily assume all risks of this activity on behalf of my child. I recognize
that this activity may expose my child to some level of risk of injury. Notwithstanding these risks, I
assume them by allowing my child to voluntarily participate in VSA.
Further, I hereby:
•
agree that students will be participating in a residential program on the campus of Vanderbilt
University (hereinafter VU). As a participant, the student will be supervised by VU staff and reside at
Hank Ingram House on the Vanderbilt Commons. Students will also have access to on-campus
recreational facilities and activities;
•
understand that the activities for the sessions vary but may include the following: classroom
instruction, organized recreational and athletic games. For Session III participants only, unsupervised
walks off campus are scheduled at designated times and within stated town boundaries. These
activities are assumed upon enrollment and participation in VSA is at the risk and request of the
student;
•
agree that students are charged with knowing and abiding by VSA policies as described in VSA
publications or as articulated by VU staff. Students who fail to follow VSA policies may be asked to
leave the program. If a student is asked to leave, his or her parent or legal guardian will be contacted.
The parent or legal guardian must make immediate arrangements to remove the student from campus
at the parent or legal guardian’s expense. Students who are asked to leave will not receive a refund of
tuition or other fees;
•
understand that during VSA, students may participate in off-campus field trips. Students who are
transported off-campus for activities will travel in vehicles driven by VU staff, other Vanderbilt staff,
or hired designees. Students who are off-campus will conduct themselves at all times in accordance
with VSA policies and will be accompanied by VU staff or hired designees during trips;
•
agree that Vanderbilt is not liable for lost, stolen or damaged personal articles. Vanderbilt is also not
liable for any consequences of the student’s actions including injury to persons and property, arising
during on or off-campus periods, and I accept responsibility for reimbursement either to the injured
party or to Vanderbilt for any damages sustained by them due to my child’s actions;
•
agree that, to the best of my knowledge, the information furnished by or on behalf of the student in
connection with the student’s participation in VSA is correct and complete;
•
give permission for the student to view movies that are rated G - PG 13, as well as in-class films
and clips deemed to be of educational value, while participating in VSA. I recognize that a VU
staff member will approve of these movies before they are shown in the classroom, residence
hall, auditorium, or other setting;
•
agree that VSA has the right to alter arrangements concerning the location and/or content of the
program or travel arrangements if it deems such action is advisable;
Return to Vanderbilt PTY by April 10, 2015 for Sessions II & III and May 8, 2015 for Session I.
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VSA 2015 Welcome Documents
•
agree that if the student should suffer an injury or illness while participating in VSA or any other
activity, I authorize the employees of VU to use their discretion to have my child treated at or
transported to the nearest medical facility and I take full responsibility for that action;
•
agree to be responsible for any losses (including reasonable attorneys fees and court costs) resulting
from my child’s damage, vandalism, littering, or theft of VU property, property of a University
community member or campus visitor, or any other property used during VSA. Furthermore, I agree
to indemnify Vanderbilt for any loss or damage to the premises, facilities, or equipment during VSA.
•
understand VU personnel adhere to Tennessee state law on mandatory child abuse reporting to either
the appropriate law enforcement agency or the state hotline operated by the Department of Children’s
Service. In addition to external reporting, Vanderbilt has a mandatory internal child abuse reporting
procedure. If you have reason to believe abuse or inappropriate behavior has occurred concerning a
minor participating in a Vanderbilt University program, please consult the program director, or Risk
Management (615-936-0660), or report via the Vanderbilt hotline at 866-783-2287. The Tennessee
Child Abuse reporting hotline number is 877-237-0004.
•
agree, in consideration of Vanderbilt allowing my child to participate in VSA, to hold harmless and
indemnify Vanderbilt and its trustees, agents, officers, servants, and employees against loss from any
and all claims of ordinary negligence, demands, rights, or causes of action of any kind or nature that
may hereafter at any time be made or brought by my child, by me or anyone on my behalf, or by any
other person having a legal interest therein arising from or by reason of any and all known or
unknown, foreseen and unforeseen bodily or personal injuries, damages to property and
consequences thereof which may be sustained by my child, in consequence of any accident or injuries
on the premises of Vanderbilt or in connection with the activity, except such liability or claim of
liability as may result from gross or intentional negligence on the part of Vanderbilt. Said
indemnification shall include, but not be limited to, court costs and attorneys’ fees.
I (the undersigned parent/legal guardian) understand and agree to the preceding terms regarding the
student’s participation in VSA. I certify that the student is capable of participating in VSA and I
grant permission for the student to participate in all planned activities.
READ BEFORE SIGNING:
By signing below, I acknowledge that I am 18 years of age or older and understand that I am entitled to have an
attorney of my own choosing to review the Release prior to signing. I have read the foregoing Release in its
entirety and understand that I am signing a complete and perpetual release and bar to any and all claims of
ordinary negligence as defined above resulting from the participation in this activity by me or my child. If the
participant is not 18 years of age or older, this release must be signed by a parent or legal guardian.
Parent/Legal Guardian’s Signature __________________________Date: ________________
Parent/Legal Guardian’s Printed Name ____________________________________________
**The policies outlined in this document apply from the date signed to 9/3/2015.
Permission & Release
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VSA 2015 Welcome Documents
AUTHORIZATION TO CONSENT TO TREATMENT OF A MINOR
I, the parent/legal guardian of,
__________________________________________
Student’s Name
__________________________
Student’s Date of Birth
an unemancipated minor, who is a participant in the Vanderbilt Summer Academy (VSA), do hereby
consent to an X-ray examination, anesthetic, medical or surgical diagnosis or treatment and medical
care which is deemed advisable by and is to be rendered under the general supervision of any
physician or surgeon on the medical staff of the Vanderbilt University Student Health Center,
Vanderbilt University Children’s Hospital or other licensed medical care providers. It is understood
that this authorization is given in advance of any specific diagnosis, treatment, or medical care being
required and is to serve as specific consent to any and all such diagnoses, treatment, or hospital care
which may be deemed advisable.
I also understand that VSA does not staff medical professionals. VSA and its staff are not
responsible for overseeing student medical needs. I further authorize VU staff to dispense nonprescription analgesics for minor medical problems such as headaches, etc.
In addition, I consent to allow the physicians and staff involved in any such treatment to share
medical findings regarding this student with VSA program coordinators and staff.
READ BEFORE SIGNING:
By signing below, I acknowledge that I am 18 years of age or older and understand that I am
entitled to have an attorney of my own choosing to review the Release prior to signing. I have
read the foregoing Release in its entirety and understand that I am signing a complete and
perpetual release and bar to any and all claims of ordinary negligence as defined above
resulting from the participation in this activity by my child. If the participant is not 18 years
of age or older, this release must be signed by a parent or legal guardian.
___________________________________
Parent/Legal Guardian’s Signature
Date:__________________
___________________________________
Parent/Legal Guardian’s Printed Name
**The policies outlined in this document apply from the date signed to 9/3/2015.
Permission & Release
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VSA 2015 Welcome Documents
STUDENT HEALTH HISTORY & DISCLOSURE
Please complete all information about your child’s health. Separate forms indicating Consent to Treat and
Statements of General Health are also required for submission before a student is eligible to attend the
program. Additional information may also be found in the student handbook and the welcome packet.
At Vanderbilt Programs for Talented Youth we seek to provide a quality academic and social program to meet
the needs of gifted students and to provide a taste of college life prior to matriculation. We ask several
questions, many of which may not be pertinent, to ensure that we have appropriate knowledge of each student
so that all program participants are actively engaged in a larger academic and residential community that
encourages one another and promotes safety, security, and efficacy for all involved.
All information provided on this form is strictly confidential and will be treated as such by VSA faculty and
staff. We request this information for the health and safety of each student in our program. Failure to disclose
the requested information may result in your child being dismissed from VSA without refund.
Vanderbilt is committed to principles of equal opportunity and does not discriminate on the basis of race,
sex, religion, color, national or ethnic origin, age, disability, military service, sexual orientation, gender
identity, or gender expression.
Student’s Name: ________________________________ Date of Birth: ____________________
Parent/Legal Guardian: ___________________________________________________________
Preferred Phone Numbers: (____)______________________(____)___________________
Street Address: _____________________________________________________________
City: ____________________________ State: ________ Zip Code: _____________
Alternative Contact Information:
We will certainly call parents/guardians in an emergency, but we’ll also call if we have questions about a
student’s health. If we cannot reach a parent or guardian, we ask that you provide contact information for
someone who knows the student and with whom we can consult. We assume you have spoken to these
alternative contacts and they are willing to assist should the need arise.
1)
Alternative Contact’s Name: ______________________ Phone: _____________
Relationship to Student: ___________________________________________
2)
Alternative Contact’s Name: ______________________ Phone: _____________
Relationship to Student: ___________________________________________
Student’s Physician: ___________________________Office Phone: _____________________
Student’s Orthodontist: _________________________Office Phone: _____________________
Student’s Dentist: ______________________________Office Phone: ____________________
Other: _______________________________________Office Phone: ____________________
Health History
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VSA 2015 Welcome Documents
Insurance Information
Parents/ Guardians are financially responsible for healthcare costs. All students must have health
insurance during their term here. Please the Student Handbook for more information.
Insurance Carrier or Plan Name: ___________________________
Group #:__________
Carrier Street Address: _________________________________________________________
City: _______________
State: ___________________________ Zip: ____________
Carrier Phone: _________________________
Name of Insured: _________________________
Relationship to Student: ___________
Policy Holder’s ID Number ______________________________________________________
Front
Back
Please photocopy and attach the front and back of your insurance card.
Health History
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VSA 2015 Welcome Documents
Allergies
Circle "yes" or "no" to the following statements. Explain as indicated. Please write “N/A” if the question
does not apply.
YES
NO
Does this student have a food allergy? If yes, please explain (you can tell us about nonmedical dietary restrictions on the next page):
YES
NO
If you answered yes above, does the food allergy cause anaphylaxis or other immediate
reaction? If so, please describe the reaction and what is done to manage it:
YES
NO
Is the student allergic to any medications? If yes, please explain:
YES
NO
If you answered yes above, does the medication allergy cause anaphylaxis or other immediate
reaction? If so, describe the reaction and what is done to manage it:
YES
NO
Does the student have other significant allergies? If yes, please explain:
YES
NO
If you answered yes above, does the significant allergy cause anaphylaxis or other immediate
reaction? If so, describe the reaction and what is done to manage it:
Health History
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VSA 2015 Welcome Documents
General Physical Health
This section focuses on your child’s overall physical health. In addition to the information provided here a Physician’s
Statement of General Health form is included in this packet to be completed by your physician. Students must be
independent in their daily health care. Students in the program should not have medical conditions requiring daily
ongoing monitoring or day-by-day management by someone other than the student.
Chronic Health Concerns:
This student has no chronic health concerns and is capable of full participation in the program.
This student has the following chronic health concerns (Mark all that apply):
Asthma
Headaches
Diabetes
Menstrual Cramps
Frequent Ear Infections
Fainting
Encopresis
Seizure Disorder/ Epilepsy
Addiction
Eating Disorder
Heart Murmur
Cardiovascular Disease
Hypoglycemia
Endocrine Disorder
Other:
Please explain any marked items, including the impact of the concern on full participation in athletic
events, group activities, and classroom learning during VSA:
___________________________________________________________________________________
___________________________________________________________________________________
Mark “yes” or “no” to the following statements. Explain as indicated.
Yes
No
Has this child had surgery within the past 12 months? If yes, explain: _______________
_______________________________________________________________________
Yes
No
Does this student have dietary restrictions for non-medical reasons? (Ex: vegetarian,
Kosher, halal, etc.?)
_______________________________________________________________________
Yes
No
Will this child be bringing any special equipment for mobility (e.g., wheelchair, walker,
cane, crutches, etc.)? If yes, explain any accommodations necessary to navigate campus.
________________________________________________________________________
Please provide any additional information about special needs such as elevator/ramp/wheelchair access,
equipment to aid sleeping, hearing aids, crutches, etc. that the VSA staff needs to be made aware of:
Note: Students who use special equipment (e.g., hearing aids, walker) during the school year should
expect to continue using the same equipment at VSA.
Health History
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VSA 2015 Welcome Documents
Medication
Will this student bring any medications (including over-the counter medications to VSA?
Y
N
Please note that we stock most common non-prescription medicines, such as Aspirin and Tylenol, in the
VSA office.
Medication Name
Dose
Time(s) Given
Reason
Comments (e.g. side effects)
Example
1 pill
AM Noon PM As needed
Nausea
May upset stomach. Take with food.
Medication Policies
• Emergency medications, such as inhalers or EpiPens, may be kept in student’s rooms.
• For the health and safety of our students, all other medications, including over-thecounter medications, must be checked in with VSA staff and stored in the VSA office.
• All medications must arrive in appropriately labeled pharmacy containers.
• It is the responsibility of the student to come to the office to obtain his or her medications, as
•
•
•
prescribed.
Bring enough of each medication to last the entire session.
Students taking medications for psychiatric reasons should be on a stable medication regime, ideally
having been on the same medications(s) at the same dose for the three months prior to a student’s
arrival to VSA.
Vanderbilt Summer Academy is not responsible for missed or incorrect doses. We are a
repository for the safe-keeping of medication only.
Over the Counter Medication
The following over-the-counter medications are stocked in the VSA office and the Vanderbilt Student
Health Center. Below is a sample of medications stocked in the VSA office, please list any medications
your student is not permitted to take.
Stocked medications may include but are not limited to:
My student must not take:
Acetaminophen (Tylenol)
Antacids (e.g. Tums, Pepto, Alkaseltzer)
Oral Allergy Medication (e.g. Benadryl,
Sudafed)
Topical Ointment (benadryl cream,
hydrocortisone)
Ibuprofen
Cough Drops
Tinactin
Triple Antibiotic Cream
Chloraseptic Throat Spray
Cold Medication (e.g.
Nyquil/Dayquil)
Health History
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VSA 2015 Welcome Documents
Social, Emotional, Behavioral, and Mental Health
This section asks about the student’s social, emotional, behavioral, and mental health and his/her ability to live,
work, study, and play with other like academic peers in a residential college environment.
Circle “Yes” or “No” for each statement and provide information as requested.
Yes
No
Has the student faced a significant event that continues to impact the student's daily life?
If yes, please provide written information about the event – death of a loved one, divorce, new
sibling, family change – its impact on the student's life, and important information for VSA
staff as they work with your child: _________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Yes
No
During the past academic year, this student has seen or is currently seeing a professional to
address mental/emotional/social concerns (If yes, specify the nature of the concern and other
pertinent information for VSA staff to be aware of): __________________________________
_____________________________________________________________________________
_____________________________________________________________________________
____________________________________________________________________________
Yes
No
This student has a psychiatric diagnosis such as, but not limited to, depression, OCD, ODD,
panic/anxiety disorder, ADHD, Autism Spectrum Disorder, bipolar, other. If yes, please specify and
explain treatment: ______________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Yes
No
Yes
No
Are there any issues that that could potentially affect the students’ social or academic success
while participating in VSA (e.g., learning disabilities, extreme shyness, acute homesickness). If yes,
please explain and specify tips/interventions: _________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Are there any issues that could affect living at ease with a roommate? (Such issues could
include, but are not limited to: sleep disorders, non-traditional gender identity,
extreme sleep-walking, sleep-talking, bedwetting, chronic cough, excessive snoring, night terrors.) If
yes, please explain the extent of the living arrangement concern and its potential impact on a
roommate: _____________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Important: Legal Alert
List all information, such as legal custody, restraining orders, or other legal agreements that
impact the student's safety while attending VSA:
Health History
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VSA 2015 Welcome Documents
PHYSICIAN’S STATEMENT OF GENERAL HEALTH
Please have the student’s physician’s office complete this form, including the immunization
record. Completed form should be returned to PTY with the student’s other Welcome Packet
materials.
Re: _______________________________________________________________
Student’s Name and Birth Date
I understand that the above-named student has been accepted to attend the Vanderbilt Summer
Academy (VSA), an intensive, summer residential program for academically talented youth during
which participants attend classes, participate in sports and other recreational activities, and live in a
residence hall with other students. To the best of my knowledge, this student has no chronic
condition that would prohibit him or her from participating fully in VSA, and I have no reason to
counsel otherwise.
Physician’s Printed Name: _______________________________________________
Physician’s Signature: _____________________________ Date: _________________
Physician notes, if needed:
____________________________________________________________________________
____________________________________________________________________________
Immunization Information
Please complete all areas in the table below, recording the dates of immunizations or attaching
the student’s immunization record.
Vaccine
Required:
#1 (mo/yr)
#2 (mo/yr)
#3
(mo/yr)
Varicella --2 shots
or disease—check here □
Measles, mumps, rubella (2
shots)
Meningococcal vaccine* (given
at age 12 or older)
Tdap booster (rising 7th and
older)
Hepatitis B (3 shots)
Recommended (but not required):
Vaccine
#1 (mo/yr)
Hepatitis A
#2 (mo/yr)
*The American Pediatrics Association recommends that all students age 12 and above received the Meningococcal
vaccine. This is essential for residential living, but may be waived if the student is under 12 years of age.
Physicians Statement
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VSA 2015 Welcome Documents
MENTAL HEALTH PROFESSIONAL’S
STATEMENT OF GENERAL EMOTIONAL HEALTH
Either sign the disclosure statement or ask the student’s mental health professional to complete this form.
Completed form should be returned to PTY with the student’s other Welcome Packet materials.
Re: _______________________________________________________________
Student’s Name and Birth Date
This form is not pertinent to my child’s situation, as indicated on the Student Health Disclosure form. My
child has no concerning social, emotional, or behavioral issues that necessitate involving a mental health
professional statement.
Parent/Legal Guardian’s Signature and Date
OR
For Mental Health Professional:
I understand that the above-named student has been accepted to attend the Vanderbilt Summer Academy
(VSA), an intensive, summer residential program for academically talented youth during which participants
attend classes, attend social events, participate in sports and other recreational activities, and live in a
residence hall with other students for one to three weeks.
By signing, I attest that to the best of my knowledge, this student has no condition that would prohibit him or
her from participating fully in VSA unless indicated below, and I have no reason to counsel otherwise.
Mental Health Professional’s Printed Name: ______________________________________________
Mental Health Professional’s Signature: ___________________________________________________
(Date)
Please provide a brief explanation of your professional opinion regarding the student’s capability to succeed
at VSA. Include any reservations or recommendations you may have to ensure the student has a positive
experience as well as other information helpful for our staff to know while working with this child.
Mental Health
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VSA 2015 Welcome Documents
STUDENT & PARENT AGREEMENT OF POLICIES
I have read the Vanderbilt Summer Academy Student Handbook (enclosed in this packet or
located at pty.vanderbilt.edu/students/vsa/admitted) in its entirety and agree to abide by the
policies and procedures stated therein.
Student’s Printed Name: _______________________________________________________
Student’s Signature: ____________________________________________ Date: _________
Parent/Legal Guardian’s Printed Name: ___________________________________________
Parent/Legal Guardian’s Signature: ________________________________ Date: _________
**The policies outlined in this document apply from the date signed to 9/3/2015.
Agreement of Policies
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VSA 2015 Welcome Documents
MEDIA & DATA RELEASE
Student Name: ____________________________________________
This release is a standard media release required by Vanderbilt University (hereinafter VU) for any person participating
in an on-campus program or activity where university staff or designees may take photos and/or record video of the
participants. VSA staff often take photos of students, faculty, proctors and other staff throughout each session for use in
the end-of-session slideshow. Such photos may also be used in future Programs for Talented Youth (hereinafter PTY)
catalogs, on our website or in other media as outlined below. By signing this release, you agree to allow your student to
appear in such photos as well as in any class, activity and session photos. *
•
I authorize VU faculty, staff, the VU Media and Public Relations staff, other VU personnel and third party entities such as
newspapers and television stations to make photographs or videos of me and or my child to exhibit, publish, televise, or
otherwise show said photographs or videos for educational and related purposes and to permit others to do the same. I
understand that there is a possibility that I (or my child) may be identifiable in these photographs or videos, though my name
or my child’s name will not be published.
•
I further authorize members of the VU Media and Public Relations staff and other VU personnel, to make and publish
photographs, videos, or written/audio accounts of me (or my child) in newspapers, magazines, other publications, television,
motion pictures, Internet, or other media, which will be circulated to the general public for marketing, business, or any other
purpose, or to provide access to members of the public media to do the same. I understand that there is a possibility that I (or
my child) may be identifiable in these photographs, videos, or written/audio accounts. Often media outlets require that filmed
participants names be published. I give permission for my name or my child’s name to be given to the media.
•
I release any and all rights or claims for payment or royalties in connection with any exhibition, televising, or other showing of
these motion pictures, videotapes, or photographs, regardless of whether such exhibition, televising, or other showing is under
philanthropic, commercial, or private sponsorship, and regardless of whether a fee of admission or film rental is charged.
•
I further agree to allow VU to collect and evaluate student data such as surveys, opinions, and coursework for
research/evaluative purposes. This information may be published. Students will not be identified by name and such data will
be used to further understanding of teaching, learning, and gifted education.
•
I understand that I may refuse to sign this authorization, and that my refusal to sign will not affect my (or my child’s) ability to
participate in this activity. I understand that this authorization may be revoked in writing at any time, except to the extent that
action has been taken in reliance of this authorization.
•
I understand that the information released may be subject to re-disclosure by some recipients and may no longer be protected
by federal and state privacy rules related to health or other information.
•
I understand that VU cannot protect me/my child from being photographed, videoed or potentially identified or named on
social media sites, by others including students or their families.
•
I understand that authorization for use at individual’s request will not expire.
•
I agree to release, hold harmless and indemnify Vanderbilt University and its representatives against loss from any and all
claims of ordinary negligence, demands, rights, or causes of action of any kind that may at any time hereafter be made or
brought by my child, by me or anyone on my behalf, or by any other person having a legal interest therein arising from or by
reason of any and all known or unknown, foreseen and unforeseen uses.
READ BEFORE SIGNING:
By signing below, I acknowledge that I am 18 years of age or older. I have read the foregoing Release
in its entirety and understand that I am signing a complete and perpetual release and bar to any and all
claims as defined by the listed agreements. If the participant is not 18 years of age or older, this release
must be signed by a parent or legal guardian.
Parent/Legal Guardian’s Signature ___________________________________________Date: ___________
Printed Parent/Legal Guardian’s Name _______________________________________
*Please note that if this form is not signed, your student cannot appear in any photo taken by our staff, nor will we
be able to post any photos of your student to our Facebook or Twitter pages. Our policy is to obscure identifying
information (such as a name tag) in every student photo. **The policies outlined in this document apply from
the date signed to 9/3/2015.
Media & Data
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VSA 2015 Welcome Documents
TRANSPORTATION INFORMATION
See “Traveling to Vanderbilt” chapter of Student Handbook for more information
on traveling to/from VSA.
Student Name: ___________________________________________________
Contact phone numbers on travel days:
Parent/Legal Guardian Cell Phone: ________________________________________
Student Cell Phone: ____________________________________________________
Airport Pickup:
For students traveling alone to Nashville by air, VSA provides airport pick-up/drop-off on arrival
and departure days for $25 each way; $50 round trip (attach check for applicable amount to this
form).
Note that this service is available ONLY to students who are flying alone.
Arrival Information: How is the student arriving at VSA on opening day?
Please note, check-in begins at 3:00 pm local time.
Check applicable option below.
Student will be dropped off at campus by parent/guardian.
Student is flying alone and will need transportation from the airport to campus.
Please be advised that Delta security policies regarding unaccompanied minors may well result in additional
wait times for your student. Please call our office at 615-322-8261 if you have any questions.
Our first pickup at the airport will be at 12pm on check-in day. Please schedule a flight that arrives in
Nashville between 11:00am-4pm. Note that students will not receive the keys to their rooms until
official check-in begins at 3pm. Due to VSA program commencement student arrivals after 4:00 pm
local time are strongly discouraged.
Airline___________________________________________ Flight #_______________________
Arrival Time at BNA: ______________________________ Confirmation #____________________
Does the airline classify your student as an "Unaccompanied Minor"?
Y
N
We will send air travelers an email approximately one week prior to opening day with information on what
to do upon arrival at the Nashville airport as well names/contact information of VSA staff members who will
meet you at the airport.
Transportation
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VSA 2015 Welcome Documents
Departure Information: How is student departing from VSA on closing day?
Please note: the dormitory closes at 3:00 pm local time for Session I and 12:00 pm local
time for Sessions II & III.
Check applicable option below.
Student will be picked up at campus by parent/guardian.
Student is flying alone and will need from campus to the airport.
Please be advised that Delta security policies regarding unaccompanied minors may result in
additional wait times for your student. Please call our office at 615-322-8261 if you have any
questions.
Student is flying alone out of Nashville and will require transportation to BNA on check out day.
Please schedule your student’s departing flights as follows: For Sessions 2 II & 3III: 8am-1pm* For
Session 1I: 1pm-4pm*. Note that we can accommodate earlier departure times the day of check out if
necessary.
Airline ______________________________________________ Flight # ____________________________
Departure Time from BNA: ______________________________ Conf. # ___________________________
Does the airline classify your student as an "Unaccompanied Minor"?
Y
N
.
* A note on “Unaccompanied Minor” status: Airlines have varying policies and age-limits on this. Check with
your airline to determine whether or not they will require “UM” status for your student. Fees and restrictions
often apply and could cause delays at travel times if a required fee is unpaid. These fees are the responsibility of
families. UM travelers should schedule their departing flight from Nashville as early in our check-out window
as possible. According to airline policies UM travelers SHOULD NOT book a final flight of the day under any
circumstances.
Authorized Pickup Information
Please list all the individuals who are allowed to pick up your student. We assume
primary/secondary and emergency contacts listed are able to pick up the student. For all
others include name, phone number, and relationship to you/the student. Individuals picking
up students should be prepared to show photo ID.
Name: __________________________ Relationship: _______________ Phone: ____________
Name: __________________________ Relationship: _______________ Phone: ____________
Name: __________________________ Relationship: _______________ Phone: ____________
Transportation
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VSA 2015 Welcome Documents
ARETÉ OPTIONS & SELECTIONS
Please place a check mark (✓) by at least 5-6 Areté classes that interest you and return this sheet with your other VSA documents.
While making your selections, do not rank-order them. We cannot guarantee Areté
placements as the Areté offerings are subject to change from week to week. You will learn your Areté
placements during your first Proctor Group Meeting on opening night. Remember, Areté classes are an opportunity for you to explore
something new and different. No previous experience is necessary in any of these classes. So be open-minded and completely
fearless. Areté is a safe way to try something new, and if you’re really bold and daring, select “Surprise Me!!” and wait to see what
fun will happen!
_____GRAVITY-ONLY BOOT-CAMP
This boot camp-style fitness training will use only your body-weight
and Mother Earth to improve cardio, strength, balance and overall
health. If you want to spend this hour raising your heart rate and
breaking a sweat, this is the Areté for you.
_____FENCING
En Garde! In this introductory fencing workshop, you’ll learn
basic footwork, parry and use of foils. Fencing teaches hand-eye
coordination and strategic thinking. Plus, you’ll get to brandish a
sword (safely, of course)! All equipment and safety gear will be
provided. Instructor is an experienced fencer who will instruct
students in proper safety & technique.
_____THE ART OF THE HENNA TATTOO
No needles. It’s not permanent. Yet it’s a beautiful art form.
Learn how to design and apply henna body art to hands and arms
as well as the stories behind its symbolic and ceremonial uses in
cultures around the world.
_____MARTIAL ARTS & SELF DEFENSE
The odds are that you’ll never be attacked or mugged. Still,
wouldn’t it be nice to know what to do if you were? This class
will teach students basic techniques drawn from different martial
arts to learn effective methods of self-defense. You’ll learn
creative ways to disable an opponent no matter your height or
body strength.
_____YOGA
Meaning “to unite,” yoga promotes balance of the body and mind
through a series of postures and mindful breathing. Although
yoga has become a fashionable form of exercise, it actually
derives from an ancient Indian spiritual tradition that is more than
5000 years old. You’ll understand yoga’s enduring presence as
you leave this class centered, calm, and energized.
_____SPOKEN WORD
Explore poetry on the page and then take it to the stage. Craft and
perform original pieces in several styles of spoken word
performance, engaging with the power of rhythm and language.
Find your voice and let it fly.
_____STAGE COMBAT
Always wanted to know how onstage and on screen fights look so
real? Learn the basics of executing safe and realistic unarmed
stage combat. This workshop is led by a trained actor/combatant
who is a member of the Society of American Fight Directors
(SAFD) and will culminate in a short stage combat sequence.
____SONGWRITING
Nashville is Music City! What better place to try your hand at
writing and maybe even preforming an original piece of music.
Work with an experienced songwriter to give life to your inner
melodies.
_____JUGGLING
Even if you are all thumbs, by the end of the week you will
impress others with your agility. Not only is this class great fun, it
teaches you how to multi-task and to keep your eye on the ball.
Once you start, you won’t be able to stop.
_____CARTOONING AND CARICATURE
Animate and exaggerate. Showcase your wit and humor with pen
and paper, possibly even add a touch of satire. You’ll have a
chance to create stand-alone images, to learn the basics of
cartooning, and to amuse your friends with your visual sense of
humor.
_____SLEIGHT-OF-HAND MAGIC
Learn sneaky card tricks and other sleight-of-hand illusions to
confound your family and friends. You’ll also get to practice how
to keep your audience enthralled through your amazing tricks and
your witty magician’s banter.
_____FLASH MOB
This interactive performance experience will allow you to
combine many of your existing skills and develop some new ones
along the way. Choreography, dancing, and surprise are all
incorporated into this public, musical experience.
_____IMPROV
Jump into the fundamentals of improvisation and
performance. Participants will learn to perform spontaneous
comedic scenes based on just a few prompts and cues. Improv
also teaches valuable life skills such as listening, communication,
self-confidence and creativity through theatre games and
exercises.
_____STEP
Learn an amazing step routine in just four days! Using rhythmic
steps, stomps and handclaps, we’ll create an energetic performance
piece to rival some of the premier step-teams in the country! Stepup!
_____PITCH PERFECT
A cappella singing is more popular than ever at VU, from the
Swingin’ Dores to the Melladores. Learn to turn a popular song into
an original a cappella performance including sound effects and
percussion using only the human voice! Trained singing voice not
required. Just bring a desire to vocalize and harmonize!
_____SURPRISE ME!! I’LL TRY ANY!
Areté
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VSA 2015 Welcome Documents
STUDENT PHOTO
Please attach a recent photo of your student to the space below. Photos are a great help to us at VSA, as we
get to know many students in a short period of time. Photos will remain with student paperwork and are only
used for the purpose expressed above. Any photo is fine, as long as it clearly captures your student in a
natural, recognizable manner.
Re: _______________________________________________________________
Student’s Name and Birth Date
Photo:
Student Photo
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