Oakland Technical High School Historical Black College Tour Spring Break 2016

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1 Oakland Technical High School Historical Black College Tour Spring Break 2016 Dates: March 27- April 1, 2016 Tour Cost: $900 COLLEGES and UNIVERSITIES Spelman College, Morehouse College, Clark Atlanta University, Tuskegee University, Alabama State, Tugaloo college, Jackson State University, Dillard University, Xavier University, Southern University, Prairie View A&M University and Texas Southern University. EDUCATIONAL and CULTURAL SITES The King Center, Atlanta s Underground, Pettus Bridge (Selma), Dexter Baptist Church, Wall of Tolerance, French Quarters, River Walk and more QUESTIONS or CONCERNS Contact Ms. Alanda Turner Ms. Dora Hopson Ms. Nadirah Stills Mr. Lamar Hancock Alanda_turner@yahoo.com dorahopson@gmail.com nadirahstills@sbcglobal.net lamarhan@gmail.com 1

2 OT High School HBCU Tour Spring 2016 STUDENT CRITERIA EVERY STUDENT: Must be an Oakland Technical High School student 10 TH 12 TH Grade Minimum GPA of 2.00 ( see Principle Morrison for exceptions) Behavior Recommendation from official Oakland Tech. Administration Pre-Tour Mandatory Parent and Student Meetings FINANCIAL OBLIGATIONS This contract must be accompanied with a minimum deposit of $300 is due by OCTTOBER 30, SUBMIT COMPLETED APPLICATION WITH FIRST DEPOSIT. SUGGESTED PAYMENT SCHEDULE First Deposit $300 by 10/30/15 Second Deposit $300 by 12/15/15 FINAL PAYMENT $300 by 2/14/16 FINAL PAYMENT must be paid by FEBRUARY 14, Make funds available to: Oakland Tech. PTSA Note on Money Order: Student s name and HBCU Tour 2016 There will be a $100 non-refundable fee. No refunds after December 1, Tour Committee reserves the right to accept/reject contracts. Deposits will only be accepted for approved students. Completed contracts with deposit on are a first come first serve basis. Contracts received after the first 40 will be placed on a holding list. Please notify one of the tour representatives immediately if a payment plan is needed other than what is listed above. 2

3 OT High School HBCU Tour Spring 2016 Due to the REFUND policy, please make certain, before entering into this legal contract that you and your child/children wish to be included in this tour experience. Be advised that by signing this contract, you agree to abide by the following conditions and you thoroughly understand ALL of the rules and regulations. 1. I have read and understand all policies, rules, student code of conduct and regulations. Students Initials. Parents Initials 2. In the event that the chaperone(s) find it necessary to return your son/daughter to Oakland, California or their home city, during the tour experience for violating policies, rules and regulations, the parent will be financially responsible. Students Initials. Parents Initials 3. I/we,, will make the necessary travel arrangements to return my child home and assume all financial liabilities. I will provide ALL pertinent information to OT HBCU tour chaperones for safe travels. Parent Signature Date Student Signature Date 3

4 Student: OT High School HBCU Tour Spring 2016 Personal Information Student Name Address City/State Zip Gender M or F Grade Age Date of Birth Home # Cell # Parent/Guardian: Parent/Guardian Name: Address City/State Zip Home # Work # Cell # Additional Information: (Please add here) 4

5 OT High School HBCU Tour Spring 2016 EMERGENCY CONTACTS: We must be able to reach the contact name and number at all times during the tour. If you are listed as parent/guardian, DO NOT list your name as one of the emergency contacts. Please inform those parties that are listed that we may have to contact them. 1. Name Relationship to student Home # Work # Cell # 2. Name Relationship to student Home # 3. Name Relationship to student Home # Work # Cell # 5

6 STUDENT S MEDICAL INFORMATION This information must be filled out completely. THIS IS NOT OPTIONAL. 1. Parents/Guardians need to make sure that your child has a card or copy of their medical insurance company and policy number on them. 2. Please provide a list of medications that the student must take. Please print the administering information as listed on the medicine bottle and directed by the doctor. We also require a list of any and all medical concerns and conditions. ALL medication must be given to tour chaperone. PLEASE complete the Insurance information: Medical Insurance Company Insurance Company Phone Policy No. DOES OT HBCU Tour Representatives HAVE PERMISSION TO ADMINISTER OVER THE COUNTER MEDICATION TO YOUR CHILD? (Aspirin, Tylenol, Allergy medication, etc ) Yes No MEDICATIONS (Print medications as labeled on medicine bottle & when it should be administered) Name of Drug Dosage (mg, #of puffs, etc.) Frequency (# of times per day) Please list any Allergies or Adverse Reactions that you may have had: Medication or substance that caused reaction What kind of reaction did you experience? When did/does this reaction occur? I,, have completed the Medical Information Form, provided ALL requested documentation as it pertains to my child s medical needs. I have also meet with Tour Staff to discuss further details. Signature of Parent/Guardian Date 6

7 AUTHORIZATION FOR RELEASE OF RECORDS AND INFORMATION PARENTS and STUDENTS MUST SIGN BEFORE SENDING TO SCHOOL TO BE COMPLETED. The signatures acknowledge that you understand and agree to the OT HBCU Tour obtaining any and all information provided by the school representatives. SCHOOL NAME ADDRESS PHONE Ext. ATTENTION Oakland Technical High School Principle or Representative REGARDING STUDENT S NAME You, or a designated representative, may use your/their judgment when providing information to a Historically Black College and Universities Tour representative. Any and all personal opinions, recommendations and information requested regarding the students behavior, social, disciplinary, and educational development will be used for the purpose of determining the students qualifications for participation in the annual tour experience. Signature of School Representative Printed name of School Representative Representatives Title Date a. Should the Traveling Guardian in his / her sole discretion (which discretion shall not be unreasonably exercised) deem it advisable to make special travel arrangements for the Child to be returned home due to any unforeseen circumstances arising, I accept full responsibility for the additional costs which shall be incurred thereby. b. I relinquish the Traveling Guardian against any and all claims whatsoever and howsoever arising, save where such claims arise from negligence, gross negligence or willful intent during the specified period of this Travel Consent. c. I declare that I am the parent/legal guardian of the Child and that I have legal authority to grant travel consent to the Traveling Guardian for the Child. d. Unless inconsistent with the context, words signifying the singular shall include the plural and vice versa. Signature (Parent / Guardian) Date Signature (Parent / Guardian) Date 7

8 MEDIA/PHOTOGRAPHY: CONSENT AND RELEASE FORM Please complete this consent form in order to allow you and/or your child (ren) to be photographed, video and/or interviewed during the annual tour and other special events of the Historically Black College and Universities Tour. I hereby consent and authorize a member(s) of the Oakland Technical High School HBCU committee to take photographs or motion pictures of me; or to produce videotapes, audiotapes, closed circuit television programs, web casts, or other types of media productions that capture my name and/or my child (ren), voice, and/or image (any of the foregoing types of media are called the Materials in this Consent and Release form). I authorize OT HBCU Tour members to copyright the Materials, and I authorize OT HBCU Tour to use, reuse, copy, publish, display, exhibit, reproduce, license to third party, and distribute the Materials in any educational or promotional materials or other forms of media, which may include, but are not limited to university publications, catalogs, articles, magazines, recruiting brochures, websites or publications, electronic or otherwise, without notifying me. I also agree that OT HBCU may identify me by name and/or my child (ren), course of study, and such other identifying information as class year, graduation date, hometown, etc. (If you and/or your child(ren) do not wish to be identified by name, etc., please cross through this sentence, please initial and indicate year.) Initial 20 I have read and agreed that I am participating on a voluntary basis and I will not receive any payment from OT HBCU Tour for signing this release or as a result of any publication of the Materials. Parent Signature Date Print Name Student Name 8