JUNIOR COUNSELOR APPLICATION

Transcription

1 JUNIOR COUNSELOR APPLICATION NEBRASKA S HEALTH SCIENCE CENTER MUNROE-MEYER INSTITUTE Science Education Partnership Award Dear Student, For an opportunity to careers in health and science, participate in the 9 th Annual SEPA Health and Science Fun Camp being held in partnership with University of Nebraska Lincoln in Lincoln, NE June 5 8! This event is for students who will be enrolled in the 6 th, 7 th, or 8 th grade next year at one of our SEPA partner schools. Since this is a FREE camp, space is limited to the first 6 students per school. Spots will be filled in the order the applications are received. If any schools do not fill the allotted spots, alternates will be selected from other schools. If you decide to participate, we will send you detailed information and maps at a later date: Applications and ALL completed forms must be received before Wednesday, MAY 11 This camp was designed for learning about science and health care in a fun environment. This year s summer camp will focus on the science of HEALTH and BIOMEDICINE! Sunday afternoon - you will arrive around 3:30 pm and check into a residence Hall the Creighton University Campus in Omaha, NE. You will meet your camp mates over dinner and then participate in an evening of planned fun activities. Monday - you will spend time at the Omaha Zoo learning about animal medicine. The day will conclude with an evening movie and some fun games. Tuesday - you will spend time at the university of Nebraska Medical Center campus doing nursing, pharmacy, brain health, body mechanics, and cytogenetics activities. Wednesday morning - you will spend the morning learning about robotics and technology in medicine. In order to participate, students must be present from Sunday evening until the camp ends on Wednesday. Transportation & Meals Each partner school or community will be responsible for providing at least 1 chaperone/school sponsor for their students. Your parents or your school will need to provide transportation to and from Omaha, NE. Transportation for all the activities while you are attending the camp and all your meals (Breakfast, Lunch, and Dinner) will be provided each day. Arrival and Lodging You will need to arrive in Omaha, NE around 3:30 pm on Sunday. More information will be sent to the school chaperones about housing arrangements. You will share a room with another camper or two of the same gender. The dorm facility will provide 2 bed sheets, 1 pillow with pillowcase, 1 blanket, 1 towel, 1 small bar of soap. You will need to bring your own toiletries (shampoo, washcloth, sponge, etc). Departure You must depart from the Residence Hall by 1:30 pm on Wednesday, June 8 th. If you have questions, contact the camp coordinator at the number listed below. We hope to see you in June! Sincerely, Liliana Bronner, Camp Coordinator (402) Note to Parent/Guardian: Enclosed please find a parental consent form. Before we may ask students what they liked and learned from the Science Camp, in order to improve future Science Camps, and record student answers, a parent must give permission by signing this consent form. Please read over the enclosed form, sign, date and return it with the student registration materials. If you have any questions about the form or the Science Camp, please contact Maurice Godfrey, Ph.D. at x Nebraska Medical Center Omaha, NE Phone: Fax:

2 CAMP ACTIVITIES Sunday Chemistry Show Science Games Monday Animal Medicine at the Omaha Zoo Tuesday Nursing Pharmacy Brain Health Body Mechanics Cytogenetics Simulation Technology Wednesday Robotics and Technology in Medicine For more information: Website: unmc.edu/sepa Phone: (402) SEPA Health & Science Fun Camp JUNE 5-8, 2016 at the University of Nebraska Medical Center & Creighton University This camp will help participants connect real-world situations with science. Students will spend time watching demonstrations and doing hands-on activities designed to teach introductory biomedical and health science concepts in fun and entertaining ways!

3 SEPA Health and Science Fun Camp at University of Nebraska Medical Center and Creighton University in Omaha, NE (June 5-8, 2016) Junior Counselor Application Form To be eligible for a camp counselor position, students must be in high school or college, and be recommended for the position by a school official. If the Junior Camp Counselor applicant is under 19 years of age, this form must be completed by a parent of legal guardian. Applicant s Full Name (Please Print) (first) (m.i) (last) Current Grade: Birthdate Name as you want it to appear on nametags, certificates, etc Male Female Address City State Zip Home phone ( ) - Name of school that student attends: Please provide an address where camp staff can a parent or guardian communication related to this camp What does student want to be when s/he grows up? Please check the preferred T-Shirt size: (adult sizes) Small (34-36) Medium (38-40) Large (42-44) X Large (46-48) 2X Large (50-52) 3X Large (54-56) Ethnicity Check the ethnic/racial categories that your child identifies with Native American White/Caucasian Black/African American Hawaiian/Pacific Islander Asian Hispanic/Latino Other (specify) List any physical restrictions/limitations or pre-existing medical conditions camp coordinators should be aware of: List allergies the participant has to any food, plants, insects or medications and the reaction to each: Are there any dietary needs we should keep in mind in regard to any snacks or meals? Allergies Vegetarian Vegan Kosher Health Insurance Information: Health Insurance Company Covering the Junior Counselor Name of Policy Holder Policy ID # Group/Plan # I am the parent/legal guardian of, who is under the age of 18 years and who wants to participate in the Health and Science Fun Camp. In consideration of my child s participation in the program, I hereby release and discharge the University of Nebraska, its employees, agents, volunteers and assigns (the Releasees ) from any and all liability, claims, claims for relief, damages, actions, causes of action and actionable wrongs of any kind, even if arising from the negligence of the Releasees, arising at law or in equity as a result of any and all actions and/or omissions of the University of Nebraska, its employees, agents, volunteers for damages or injuries occurring to my child arising out of my child s participation in the camp program, whether such liability or claim arises from an injury occurring on the University of Nebraska premises or elsewhere. I understand that the Health and Science Fun Camp staff is not trained or required to administer injections or medications or to perform medical procedures. I understand that the University of Nebraska will allow participants with parental permission to self-administer medications and/or injections where such medications and/or injections are physician ordered and directed. My child has my permission to participate in all session and field trip activities. In case of emergency, I hereby request and authorize any health care provider to provide treatment promptly, whether or not I may be contacted and informed. I understand that I will be notified as soon as possible in the event of an emergency. I further authorize the camp staff to examine and render emergency or urgent medical care as they deem necessary.

4 In case of an emergency, who to you want us to notify: Name: Name: Relationship to Child: Relationship to Child: Daytime Phone: ( ) - Daytime Phone: ( ) - Mobile Phone: ( ) - Mobile Phone: ( ) - Media Release Authorization: These materials can cannot contain my child s name. I do do not consent and authorize University of Nebraska, its employees, agents, and event partners to take photos, produce newspaper or magazine articles, television programs, video recordings, and other visual and/or audio recordings in which my child may be included in whole or in part. I understand that my child s photograph may be used for educational and public relations purposes. I waive any proprietary rights in the materials and any right to inspect or approve the finished materials prior to publication. I release the University of Nebraska Medical Center, its employees, agents, and event partners from any claims arising from the use of such materials. I understand that short skirts/shorts, midriff tops, spaghetti straps, and the display of undergarments are not appropriate attire for this camp. I will ensure that my child has appropriate clothing for this event. For the safety of my child, I will also ensure that my child has closed-toed footwear available to wear during camp activities. I understand that the camp director reserves the right to refuse or dismiss a camper for just and reasonable cause. There is a no tolerance policy on fighting, stealing, using weapons of any kind, smoking, using drugs, and drinking alcohol. If my child engages in any of these behaviors, my child will be suspended and local law enforcement may be contacted. I understand that my child will be asked to immediate leave and vacate camp premises. I understand that I will be asked to pick up my child immediately, at my own expense. I understand that no refund or compensation will be issued in this case. To be eligible for a Junior Camp Counselor position, students must be in high school or college, and be recommended for the position by a school official. Junior Camp Counselors are compensated $ 175. This is a round-the-clock 3 ½-day commitment. Junior Camp Counselors are assigned a dorm room which they will share with another camp counselor of the same gender for the duration of the camp. Junior Camp Counselors will have to effectively perform key tasks in order to receive payment for this service. List of key Junior Camp Counselor tasks: Each evening: Have available some evening activities for the camp participants (cards, board games, etc). Each morning: Make sure to count all participants students & chaperones as they enter the bus. Each day: Ensure that camp participants understand the activities and help staff with any tasks if needed. Be a good role model. PARENT/GUARDIAN: Do you agree having your child compensated for serving as a Junior Counselor for this event. Yes No If your answer is yes, you must provide a social security number for the University of Nebraska to write a check to your child - - This check will be sent to the address provided below about four weeks after the camp has ended. Please provide the mailing address where you want the check to be sent: Address City State Zip I understand that my child s participation as a Junior Camp Counselor in the Health and Science Fun Camp is contingent on signing this application form. Parent/Guardian Printed Name Parent/Guardian Signature Date This camp is supported by federal grant funds # OD from National Institutes of Health. Space is limited. Positions will be filled in the order that the complete applications are received. All required forms must be received before May 11 Return the following completed documents: 1. Junior Counselor Application Form (2 pages) and 2. IRB Parental Consent (2 pages) to participate in the Summer Camp by standard envelope to the following address: Liliana Bronner, SEPA Camp Coordinator Nebraska Medical Center, MSB 2526 Omaha, NE Or Fax To (402) For more information, call the SEPA staff at (402) Scan and LBronner@unmc.edu

5 IRB PROTOCOL # EP Page 1 of 3 IRB PROTOCOL # EP Page 2 of 3 NARRATIVE CONSENT SUMMER SCIENCE CAMP Title of this Research Study Accelerating Access: Health Science Education in Native American Communities The University of Nebraska Medical Center and the Great Plains Tribal Chairmens Health Board invite your child to participate in a weeklong summer science experience, as well as participate in a research study where he/she would answer questions about his/her experience at the camp. The science camp will be held on the campus of University of Nebraska Medical Center in Omaha, NE June 5-8, 2016 The University of Nebraska Medical Center has been working with teachers in your community to enhance science education in grades K-8. We would like to bring some of these experiences to your child directly. Your child is eligible to participate in this camp because he/she attends one of our partner schools and is enrolled in the 6th, 7th, or 8th grade. Your child is eligible for the research study if they attend the camp. The purpose of this camp is to increase the appreciation and awareness of science and scientific and health care careers. The camp curriculum will be a mixture of pure science and health career exploration centered around a theme. The camp will provide for enrichment that goes beyond the regular classroom experience. As part of the research study, your child will be asked to answer questions each day related to the activities in which they have participated. It will take him/her minutes to answer these questions. Your child does not have to answer any or all of the questions. The feedback will be reviewed by the researchers to find ways to improve the camp in future years. One of the known risks is the possible loss of confidentiality in the answers submitted by your child. By participating in this camp, your child may learn and apply scientific concepts. This may benefit your child as he/she continues his/her education; however, your child is not expected to receive any benefit from answering the questions related to the research study. There will be no cost to you for your childs participation in the camp or the research study. You or your child will not be compensated for participation in the camp or the research study. The University of Nebraska Medical Center has been funded by the National Institutes of Health for a grant entitled: Accelerating Access: Health Science Education in Native American Communities. Your child's welfare is the concern of every member of the camp personnel and the research team. During the camp your child may be photographed. In the interest of education and the advancement of the health sciences, the photographs taken may be used to produce newspaper/magazine articles or television news stories in which your child may be included in whole or in part. The photographs may be released to hometown newspapers and to the Omaha local media. You have the option as to whether or not your child is photographed. No information that identifies your child will be released to anyone without your explicit permission. Your child has rights as a research subject. These rights are explained in this consent form and in The Rights of Research Subjects that you have been given. If your child has a problem as a direct result of participating in the camp or being in this study, you should immediately contact one of the people listed at the end of this consent form. If your child does not wish to continue attending once the camp has started there is no obligation to continue. Your child can decide not to be in the research study (answering the questions about their camp experience), or your child can stop being in this research study (withdraw) at any time before, during, or after the camp begins. Your child can still attend the camp even if he/she is not in the research study. Deciding not to be in or withdrawing from the study will not affect your childs relationship with the investigator, the camp personnel or with the University of Nebraska Medical Center. You are freely making a decision whether to allow your child to attend the camp and whether to enroll your child in the research study. Signing this form means that (1) you have read and understood this consent form, (2) you have had the consent form explained to you (3) you have had your questions answered and (4) you have decided to allow your child to attend the camp. IRBVersion 4 Subject's Initials IRBVersion 4 Subject's Initials

6 IRB PROTOCOL # EP Page 3 of 3 If you have any questions concerning your or your child's rights, or complaints about the research, talk to the investigator or contact the Institutional Review Board (IRB) by telephone (402) , IRBORA@unmc.edu, or mail: UNMC Institutional Review Board, Nebraska Medical Center, Omaha, NE If you have any questions about the camp at any time, you should talk to one of the investigators listed below. Information about the camp will be posted on You will be given a copy of this consent form to keep. Printed Name of Student Participant Printed Name of Parent/Guardian You have decided to allow your child to participate in the research portion of the camp as explained in this consent form (please circle) YES NO Signature of Parent/Guardian Date / / For office use only: Principal Investigator: Maurice Godfrey, Ph.D. (402) or extension 6689 Secondary Investigators: Liliana Bronner, MHSA (402) What Do I Need To Know Before Being In A Research Study? Institutional Review Board (IRB) You have been invited to be in a research study. Research studies are also called "research surveys", "research questionnaires" or "scientific protocols." Research is an organized plan designed to get new knowledge about health, disease, behaviors, attitudes and interactions of, among and between individuals, groups and cultures. The people who are in the research are called research subjects. The investigator is the person who is running the research study. You will get information from the investigator and the research team, and then you will be asked to give your consent to be in the research. This sheet will help you think of questions to ask the investigator or his/her staff. You should know all these answers before you decide about being in the research. What is the purpose of the research? Why is the investigator doing the research? What are the risks of the research? What bad things could happen? What are the possible benefits of the research? How might this help me? How is the research different than what will happen if I m not in the research? Will being in the research cost me anything extra? Do I have to be in this research study? How will it affect my status at the institution if I say no? Can I stop being in the research once I ve started? How? Who will look at my records? How do I reach the investigator if I have more questions? Who do I call if I have questions about being a research subject? Make sure all your questions are answered before you decide whether or not to be in this research. Signature of person documenting consent Date Received / / IRBVersion 4 Subject's Initials Academic Research & Services Building 3000 / Nebraska Medical Center / Omaha NE / FAX / irbora@unmc.edu /

7 Institutional Review Board (IRB) THE RIGHTS OF RESEARCH SUBJECTS AS A RESEARCH SUBJECT YOU HAVE THE RIGHT to be told everything you need to know about the research before you are asked to decide whether or not to take part in the research study. The research will be explained to you in a way that assures you understand enough to decide whether or not to take part. to freely decide whether or not to take part in the research. to decide not to be in the research, or to stop participating in the research at any time. This will not affect your medical care or your relationship with the investigator or the Nebraska Medical Center. Your doctor will still take care of you. to ask questions about the research at any time. The investigator will answer your questions honestly and completely. to know that your safety and welfare will always come first. The investigator will display the highest possible degree of skill and care throughout this research. Any risks or discomforts will be minimized as much as possible. to privacy and confidentiality. The investigator will treat information about you carefully, and will respect your privacy.... to keep all the legal rights you have now. You are not giving up any of your legal rights by taking part in this research study. to be treated with dignity and respect at all times The Institutional Review Board is responsible for assuring that your rights and welfare are protected. If you have any questions about your rights, contact the Institutional Review Board at (402) Academic Research & Services Building 3000 / Nebraska Medical Center / Omaha NE / FAX / irbora@unmc.edu /