DIBAAJIMO-TAA: The Summer Institute of Aboriginal Storytelling and Filmmaking Registration Package

Transcription

1 DIBAAJIMO-TAA: The Summer Institute of Aboriginal Storytelling and Filmmaking Registration Package DIBAAJIM-TAAO, The Summer Institute of Aboriginal Storytelling and Filmmaking The Summer Institute of Aboriginal Storytelling and Filmmaking offers a one-week program for students to explore how to tell stories both orally and visually through traditional storytelling and filmmaking practices. The Institute is aimed at Aboriginal students in Grades 7 & 8 and who want a unique summer experience. Participants live in residence at Laurier, learn about storytelling and filmmaking, and participate in various physical and cultural activities in Waterloo Region. Youth Information Last Name: REGISTRATION DEADLINE: August 1, 2016 Please complete all sections. Incomplete forms cannot be processed. First Name: Male Female Number and Street Address: City, Province: Postal Code: School and School Board: Age (as of September 2016): Birth Date (mm/dd/yyyy): Parent/Guardian Information Name: Home Phone Number: Work Phone Number: Cell Phone Number: Address (if different from Youth): Emergency Contact (if Parent/Guardian unavailable): Relationship to Youth: Phone: Names of ALL persons, including parents, who have permission to drop-off or pick-up your youth: *** MANDATORY ***

2 DIBAAJIMO-TAA Privacy Statement: Personal information from individuals involved in the DIBAAJIMO-TAA Film & Storytelling Institute (including name, address, phone number, and address) is collected and printed, but will not be shared with any other outside organization. Personal information is for use by Laurier as a means of communication for all events pertaining to the DIBAAJIMO-TAA Film & Storytelling Institute. Laurier must adhere to guidelines pursuant to the Freedom of Information and Protection of Privacy Act specifically regarding the protection of personal information. Parents/guardians of those under the age of 18 are to be informed of the potential uses of their child s personal information. During the DIBAAJIMO-TAA Film & Storytelling Institute, youth will be involved in a variety of Aboriginal-related activities and events. There are situations where personal information might be used for promotional and/or marketing reasons, as listed below. PART A: i) Specific information from the Registration Form (name, phone number and contact information) may be provided to the staff for communication purposes, as required. ii) Names, photographs, videos and/or auditory recordings may be used for newsletters, displays, individual camp photo CDs if applicable, and local television, radio and newspaper media for informational and/or marketing related purposes. iii) Emergency and Medical Personnel Names, addresses, telephone numbers, and birthdates, as well as the names, addresses and home/work telephone numbers of their parents/guardians, are shared with medical and/or other emergency personnel when circumstances demand it. PART B: Internet & Website use of photographs and voice recordings Photographs and voice recordings may be used on our DIBAAJIMO-TAA Film & Storytelling Institute website for camp related activities. Names and full faces are not used re. photographs on the Internet unless there is written consent from every member contained in the photo. PART C: I have read DIBAAJIMO-TAA Film & Storytelling Institute s Standard Release Form and give permission for the DIBAAJIMO-TAA Film & Storytelling Institute to use my child s personal information, based upon the preceding conditions outlined in Part A and Part B of this form. *** If you have any objections with any of the above, please indicate your concerns in the comments section below. *** Name of Youth: Name of Parent/Guardian: Phone Number: Date: Signature of Parent/Guardian: Comments:

3 Medication must be authorized by the Camp Co-ordinator or designate prior to administering. Please Note: It is understood that the preferred practice is that all medication be administered by the parent/guardian at home during non-camp hours. If a medication must be administered during camp hours, it is suggested that your physician be consulted, to prescribe an alternative medication that does not require administration during camp hours, if possible. Please complete the Administration of Medication Authorization Section of this form for any prescribed medications to be taken while at DIBAAJIMO-TAA Film & Storytelling Institute. Over-the-counter medications will not be dispensed to any DIBAAJIMO-TAA Film & Storytelling Institute participant, unless prescribed by a physician. To be completed by Parent/Guardian Name of Youth: Birth Date (mm/dd/yyyy): Full Health Card Number: Number and Street Address: City, Province: Postal Code: Name of Physician: Address of Physician: Phone number of Physician: Are there any specific medical concerns/allergies of which we should be aware? No Yes If yes, please describe. Please list all medications being routinely taken (including over-the-counter or non-prescription drugs), as well as their dosage and frequency. Medications sent with your youth must be in the original bottle or package. Please indicate if there is anything important that DIBAAJIMO-TAA Film & Storytelling Institute personnel should know with regard to your child s social, emotional, interpersonal, or behavioural needs:

4 ADMINISTRATION OF MEDICATION AUTHORIZATION if applicable Medication may be self-administered by the DIBAAJIMO-TAA Film & Storytelling Institute participant. (Provide details below.) Medication must be administered by DIBAAJIMO-TAA Film & Storytelling Institute personnel: I, authorize the administration of (name of medication) to my child for (reason) by DIBAAJIMO-TAA Film & Storytelling Institute Coordinator or designate. Date prescription started / / Date medicine started at Camp / / Times of Administration: Dosage: Has this medication been prescribed by a physician? Yes No No Prescribing physician s name: Is refrigeration required? Yes Phone number: Special Instructions be specific (e.g. Must be taken with food, Administer epi-pen to thigh after exposure to nuts and difficulty breathing and/or swelling of the lips/tongue/throat, then call 911, etc.) Possible Side Effects:

5 FOR ALL DIBAAJIMO-TAA Film & Storytelling Institute Youth Parents/Guardians: Please read the following, sign below and submit as part of the registration form. 1. In the event of an emergency and/or special medical treatment, parent/guardian(s) will be notified immediately. If the parent/guardian(s) cannot be reached, permission is hereby given to DIBAAJIMO- TAA Film & Storytelling Institute personnel to take whatever steps it deems necessary to ensure the safety and health of my child. This also gives DIBAAJIMO-TAA Film & Storytelling Institute personnel permission to get in touch with the emergency contact and/or my child s physician. 2. As the parent/guardian of the above-named youth, I request and authorize DIBAAJIMO-TAA Film & Storytelling Institute personnel to administer prescribed medication referred to in the accompanying Medical Form, using the procedures outlined above. Also, I acknowledge DIBAAJIMO-TAA Film & Storytelling Institute personnel are not medically trained to administer medications. 3. I understand and accept that if questions arise about the administration of medication, the camp leader/designate will contact the parent/guardian to come to camp and administer the medication. Therefore, it is the responsibility of the parent/guardian to ensure that all medication is in the original container and all information regarding dispensing is clearly marked. 4. No more than the daily dose(s) of any prescribed medication is to be sent to the DIBAAJIMO-TAA Film & Storytelling Institute at any time unless other arrangements are made with the Camp Co-ordinator prior to the start date. 5. I also understand and accept that if problems arise with the administration of the medication (i.e., refusal by the youth to take the medication, complaints of side effects, possible allergic reactions, etc.), the camp will immediately discontinue further doses and inform the parent/guardian. Any changes made to the administration regimen must be outlined on a new medical form. 6. I understand and accept that the camp leader/designate can reserve the right to refuse to administer treatment to the youth if the necessary information is not provided by the parent/guardian. 7. I hereby release Laurier, its employees, agents and volunteers from all manner of actions, causes of actions, suits, losses, damages or injuries, however caused, arising out of the administration or failure to administer medication as provided herein. I do also hereby indemnify Laurier, its employees, agents and volunteers for any losses or damages sustained by them as a result of such actions or proceedings being commenced against them by myself or the camper or any other parent or guardian of said camper. 8. I hereby acknowledge that I have read and fully understand the terms, policies and conditions set out herein. Parent/Guardian Signature: Date Signed:

6 Please keep these pages for future reference do not submit them with the registration form Eligibility POLICIES & CONDITIONS DIBAAJIMO-TAA Film & Storytelling Institute programs are open to Aboriginal youth currently in Grades 7 or 8. Others may be admitted pending approval of the DIBAAJIMO-TAA Film & Storytelling Institute Coordinator. Camp Hours and Location This is an overnight camp, which means participant will be supervised throughout the day and overnight. The DIBAAJIMO-TAA Film & Storytelling Institute programming will run each day from 9:00am-7pm. Participants will be provided breakfast, lunch and dinner; with snacks periodically during the day. Participants will have evening programming after 7pm, but will also be allowed free-time in the evenings. Parental Expectations We ask that all parents/guardians drop off and participant in the Parent/Youth Luncheon on Sunday August 7 th and be present for the DIBAAJIMO-TAA Film & Storytelling Institute film screening on Sunday August 14 th. The times and locations will be sent in the parent . Peanuts/nuts DIBAAJIMO-TAA Film & Storytelling Institute strives to create a nut-free environment, but cannot guarantee it. It is asked that all food (lunches and snacks) sent to camp is nut free. Please make sure to fill out the DIBAAJIMO-TAA Film & Storytelling Institute medical form if your child has an anaphylactic allergy to nuts or any other food. Safety & Liability Laurier, its employees, DIBAAJIMO-TAA Film & Storytelling Institute, agents and volunteers shall not be held responsible for any damage, loss or claim of injury resulting from events beyond its control, including acts of God, strikes, or sickness. Laurier cannot be held responsible for events resulting from inappropriate or irresponsible youth behaviour. DIBAAJIMO-TAA Film & Storytelling Institute personnel will deem what is appropriate behaviour and computer use, and their decisions will be final. Violations may lead to parental contact and possible removal from film institute.

7 Please keep these pages for future reference do not submit them with the registration form DIBAAJIMO-TAA Film & Storytelling Institute Participant Expectations Laurier s DIBAAJIMO-TAA Film & Storytelling Institute has a non-tolerance policy for misconduct which puts any DIBAAJIMO-TAA Film & Storytelling Institute participant or DIBAAJIMO-TAA Film & Storytelling Institute personnel at risk. This includes, but is not limited to, inappropriate actions towards another person, and improper computer use which violates Laurier s computer policy. The following are examples of improper behaviour: - harassing or threatening other users - using abusive, vulgar and other inappropriate language - vandalism of accounts or systems - accessing adult-only computer sites DIBAAJIMO-TAA Film & Storytelling Institute may terminate an Aboriginal youth s participation if his/her willful misconduct or actions interfere with the operation of the program. Laurier has the right to hold DIBAAJIMO-TAA Film & Storytelling Institute youth or parents financially responsible for any damages or loss of property incurred at their program site due to a DIBAAJIMO-TAA Film & Storytelling Institute participants willful misconduct or irresponsible actions. Further details Close to the camp date, you will receive an with final details such as drop off/pick up locations and procedures, maps, and parking instructions. Please contact the following people if you have any questions: Cara Loft x.4312 Aboriginal Students Recruitment and Outreach Officer, Office of Aboriginal Initiatives cloft@wlu.ca