GenCyber Scholarship Camp Program 2014The University of Arizona
UNIVERSITY OF ARIZONA INTERACTIONS WITH NON-ENROLLED MINORS
PROGRAM PARTICIPANT INFORMATION FORM
GenCyber Scholarship Camp Program 2013
Week of Attendance: _____ June 1 – 7, 2014 ____ June 8 – 15, 2014
Name of Program Participant: ______
School: ______
Date of Birth: ______
Address: ______
Phone Number: ______E-mail Address: ______
T-Shirt Size (Adult): ______
Parent/Legal Guardian Information:
______
Name Home Phone Number E-mail Address
______
Residence Phone Number
______
Cell Phone Number
______
Name Home Phone Number E-mail Address
______
Residence Phone Number
______
Cell Phone Number
Emergency Contact Information:
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GenCyber Scholarship Camp Program 2014The University of Arizona
______
Name Home Phone Number E-mail Address
______
Residence Phone Number
______
Cell Phone Number
PROGRAM PARTICIPANT MEDICAL INFORMATION AND RELEASE
Name of Program Participant: ______
Date of Birth: ______
Does the Program Participant have any medical condition(s) or limitation(s) affecting his/her ability to participate in Program/Third-party Activities?
_____ Yes _____ No
If yes, please describe: ______
______
______
If yes, does the Program Participant require any accommodations in connection with such medical condition(s) or limitation(s)?
_____ Yes _____ No
If yes, please describe: ______
______
______
Does the Program Participant have any known medication, food, or other allergies?
_____ Yes _____ No
If yes, please describe: ______
______
______
Does the Program Participant have any dietary restrictions?
_____ Yes _____ No
If yes, please describe: ______
______
______
Name of Program Participant’s Health Insurance Company: _
Policy Group Numbers:
Will the Program Participant be bringing any prescription or other medications to the Program?
_____ Yes _____ No
If yes, name each medication and provide dosage instructions exactly (as set forth on the prescription medication amount and time(s) of administration). NOTE: PROGRAM STAFF MAY NOT AUTHORIZE DEVIATIONS FROM PRESCRIPTION INSTRUCTIONS.
______
______
______
Are there any special handling instructions for the above-described medications (e.g., refrigeration)? If yes, please describe: ______Name and phone number of the Program Participant s Primary Health Care Provider: ______
I authorize the Program as follows:
1) to obtain emergency medical services as needed for my child; and
2) To store the above-listed prescription medication(s) according to original product label instructions and to provide such medication(s) to my child for purposes of permitting my child to self-administer such medications at the prescribed times according to prescription instructions.
I release and discharge the Arizona Board of Regents, on behalf of the University of Arizona, and all of their employees, volunteers, and other agents (“Releasees”) from any liability in connection with obtaining emergency medical services for my child or providing medications to my child as I have directed and authorized above. I further agree to indemnify, defend, and hold the Releasees harmless from and against all claims, demands, and suits brought against them in connection with this Release.
______Printed Name of Program Participant s Parent/Legal Guardian Date
______Signature of Program Participant s Parent/Legal Guardian
BEHAVIORAL EXPECTATIONS FOR MINORS/PROGRAM PARTICIPANTS
As a participant in the GenCyber Scholarship Camp 2013 Program, I agree to follow these Behavioral Expectations related to my conduct:
1. I will not consume alcohol if I am under the age of 21.
2. I will not bring firearms or other weapons to any Program activity.
3. I will not sell, use, possess, or distribute illegal drugs or related items that would violate the law.
4. I will not provide any legal drugs, including prescription medications or over-the-counter medications, to other Program Participants or Program Staff.
5. I will not engage in any threatening or intimidating behavior, including stalking, bullying or hazing of other Program Participants or Program Staff.
6. I will not engage in behavior that will or is intended to cause physical or emotional harm either to myself or others participating in the Program.
7. I will not engage in gambling or gaming activities.
8. I will not engage in any illegal sexual activity, sexual offenses or activities involving sexual favors.
9. I will not engage or solicit prostitution or use escort or related adult entertainment services.
10. I will not engage in any discriminatory activities, including harassment or retaliation.
11. I will abide by all state and federal laws.
12. I will not conceal an act of misconduct prohibited by these Behavioral Expectations.
13. I will only use audio or video recording devices if approved by Program Staff for purposes consistent with authorized Program activities.
14. I will report to Program Staff if I believe that any Program/Third-party Activity participant has been the subject of abuse, neglect, or physical or emotional harm.
15. I will follow directions of Program Staff.
I am aware and acknowledge that a violation of these Behavioral Expectations and regulations may subject me to removal from the Program or Third-party Activity or other sanctions at the sole discretion of Program Staff and that any expenses related to such removal or sanctions will be my/our sole responsibility.
I certify that I have read and will follow the Behavioral Expectations and regulations outlined above.
______Printed Name of Program Participant Date
______Signature of Program Participant
______Printed Name of Parent/Legal Guardian of Program Participant Date
______Signature of Parent/Legal Guardian of Program Participant
Multi-Media Consent and Release form
I, the undersigned, hereby grant The Arizona Board of Regents on behalf of The University of Arizona (the “University”) the right to videotape, film, audio record and/or photograph me and my performance in the Recordings during the GenCyber Scholarship Camp 2014. I hereby grant the University and its sublicenses, the exclusive, royalty-free rights to copyright, edit, publish, broadcast and otherwise use or disseminate all or any part of the Recordings and my voice, image and likeness contained therein, for educational, research, commercial, or promotional purposes, without condition or restriction, in whole or in part, in any medium or content whatsoever, including but not limited to, university websites, print, radio, television or any other electronic or digital forms of media throughout the universe. I also agree that there will be no residual or any other type of payment, royalty or fee due in connection with the rights granted herein. I agree to release the University from any and all claims for compensation, libel, false light, invasion of privacy, moral rights and rights of publicity
Name (please Print)
Signature
Signature of guardian if under 18 years of age
Transportation Consent and Release form
By signing below, I grant GenCyber authorized personnel permission to transport my child by motor vehicle to and from the camp activities.
Name (please Print)
Signature
Signature of guardian if under 18 years of age
By signing below, I do not grant GenCyber authorized personnel permission to transport my child by motor vehicle to and from the camp activities. My child will be transported to and from camp sites by the listed means.
Name (please Print)
Signature
Signature of guardian if under 18 years of age
Travel to the BioSphere2 for first day of camp
Travel from the BioSphere2 on last day of camp
**I would like a camp director to contact me regarding transportation.
Please mail this completed packet to:
Katy Shearman
Program Coordinator, Senior
University of Arizona
1077 N. Highland Avenue
PO Box 210073
Tucson, Arizona 85721
Principal Investigator: William T. Neumann (Management Information Systems)
1130 E. Helen St., Tucson AZ 85721
520-621-2748
Co-PIs: Salim Hariri (Electrical and Computer Engineering)
1230 E. Speedway Blvd, Tucson AZ 85721
520-621-4378
Hsinchun Chen (Management Information Systems)
1130 E. Helen St., Tucson AZ 85721
520-621-2748
Administrative Support: Katy Shearman (University Information Technology Services)
1077 N. Highland Avenue, Tucson AZ 85721
520-621-7445
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