DATE & TIME: JULY 26 JULY 30, :30a.m. - 5:00p.m.

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1 Greensboro Area Health Education Center, partnering with North Carolina A & T State University School of Nursing Offer One Week Summer Day Camp for rising 6 TH, 7 TH & 8 TH GRADE STUDENTS DATE & TIME: JULY 26 JULY 30, :30a.m. - 5:00p.m. Camp Location: NORTH CAROLINA A&T STATE UNIVERSITY, 1601 East Market Street, Greensboro, NC School of Nursing (Noble Hall) Registration Fee: $35.00 Application deadline: Friday, July 2, 2010 Students will be notified by July 9 th LUNCH & SNACKS WILL BE PROVIDED. DESCRIPTION: This is a one week day camp designed for middle school aged students who are interested in pursuing health careers, math and science. The camp will focus on introducing students to various health careers in a higher education setting while making learning fun and enjoyable. The students will participate in classes to reinforce their science and math skills at the School of Nursing at North Carolina A&T State University. The faculty will also provide an overview of Nursing and its rich history. The students will have meals, classes and activities on campus to keep them engaged all day from 8:30 to 5:00. The students will also be trained as certified Safe Sitters, which teaches them the do s and don ts of baby-sitting safely. This is a trade that they can use for life, and may provide an opportunity for to earn money baby-sitting in the future! There will be a few field trips during the week that are sure to engage the students in hands-on activities (The Aggie Farm at A&T, the City Morgue, and Moses Cone). ORIENTATION DATE: Monday, JULY 26, 2010 at 8:30a.m. prior to check-in.

2 APPLICATION FOR MIDDLE SCHOOL SUMMER CAMP GREENSBORO AREA HEALTH EDUCATION CENTER (AHEC) CO-SPONSORED BY NORTH CAROLINA A&T STATE UNIVERSITY SCHOOL OF NURSING 1601 EAST MARKET STREET GREENSBORO, NORTH CAROLINA JULY 26 - JULY 30, :30AM -5: 00P.M. Held on the campus of North Carolina A&T State University School of Nursing (Noble Hall) PLEASE PRINT. USE BLACK OR BLUE INK. Applicant Name Gender Birth date Race/Ethnic Origin Phone Number ( ) Mailing Address (Street No./PO Box (City) (State) Zip) Name of School Grade (Fall 2010) Mother/Guardian Phone No. (Home) Cell Work Address: (City) (State) (Zip) Mother s Address: Father/Guardian Phone No. (Home) Cell Work Address: (City) (State) (Zip) Father s Address: In the event parents can t be reached who should be contacted: Name (Home) (Cell)

3 Address: List any disabilities: List any allergies: List any medical condition(s) we should be aware of: List Medication(s) being taken List all school/community achievements: Are you interested in other AHEC programs? Yes No Parent Consent I, am aware ( Applicant s name) Is registering for Middle School Summer Camp and hereby give my permission for participation. Parent Signature Date REGISTRATION DEADLINE: JULY 2, 2010 Application with payment must be received by July 2, 2010 Check/Money Order payable to Greensboro AHEC Return application with a 35$ Registration fee to: Greensboro AHEC 1200 North Elm Street Greensboro, NC ATTN: HEALTH CAREERS LIMITED SPACE. REGISTER EARLY.

4 ASSUMPTION OF RISK AND RELEASE GREENSBORO AHEC MIDDLE SCHOOL SUMMER CAMP JULY 26- JULY 30, 2010 GREENSBORO AHEC/MOSES CONE HEALTH SYSTEM In consideration for participation in the Greensboro AHEC Summer Camp programs at Greensboro Area Health Education Center (AHEC) Moses Cone Health System for the purpose of exposure to health careers and academic preparation, and any other related activities. I, the undersigned, on behalf of my minor child, do for myself, my heirs, and personal representatives, agree to indemnify and hold harmless AHEC and Moses Cone Health Systems and all their respective directors, officers, employees, volunteers, and agents from and against all claims, damages, demands, actions, or causes of action, on account of damaged to personal property, personal injury or death, arising or occurring as a result of my minor child participation in the program. I also fully recognize and appreciate the risks associated with the program to which my minor child may be exposed during his/her participation in the Program and do hereby assume all the risks and responsibilities surrounding my minor child s participation in the Program or any other activities associated with the Program. I hereby attest and verify that I will assume and pay my own minor child s medical expenses and emergency expenses in the event of an accident, illness, or other incapacity, regardless of whether I have authorized such expense. I further attest that my minor child is physically fit and sufficiently trained to participate in the activities of the program. I agree and acknowledge that I shall be personally responsible and liable for the conduct of my minor child and am executing this release and indemnity as parent and legal custodian of my minor child. I also fully understand that my minor child s participation in the Program is voluntary, and that my minor child is not required to participate. I also accept full responsibility for my minor child s use of any facilities, including private and public property; and agree to make full restitution with regards to any compensation required as a result of my use, misuse of, or damage to such properties. In witness whereof, I have caused this release to be executed this day of, Signature of Parent or Guardian Printed Name of Minor Child

5 NORTH CAROLINA AGRICULTURAL AND TECHNICAL STATE UNIVERSITY MEMORIAL STUDENT UNION LIABILITY WAIVER (all parentsllegal guardians must sign below) I,, being the parentflegal guardian of agree that in no event shall North Carolina A&T State University or its agents or officers be held liable for any damages whatsoever arising out of or caused by myself or my child's participation in the from to -', located on the campus of North Carolina A&T State University. I also agree to indemnify North Carolina A&T State University for any payments, damages or any other compensation arising out of any and all legal actions resulting from or caused by myself or my child's participation in the above-stated event, including but not limited to settlements, awards, medical expenses, property damage and attorneys' fees. Parent/Legal Guardian Signature ~/_---~/_----- Date Child's Name (please print): _ A Land-Grant University and A Constituent Institution of the University of North Carolina Memorial Union East Market Street> Greensboro, NC (336) Fax (336)

6 NORTH CAROLINA AGRICULTURAL AND TECHNICAL STATE UNIVERSITY MEMORIAL STUDENT UNION LIABILITY WAIVER (All participants in Summer Activity must sign) I,, agree to indemnify North Carolina A&T State University and in no event shall North Carolina A&T State University, its agents and assigns be held liable for any damages whatsoever arising out of or caused by my participation in the summer activity of on the campus of the North Carolina Agricultural and Technical State University during the dates of, I also agree to accept full responsibility for participation in the above-stated activity, and I agree to indemnify North Carolina A&T State University for any payments, damages or any other compensation arising out of any and all legal actions resulting from or caused by my participation in the above-stated event, including but not limited to settlements, awards, medical expenses, property damage and attorneys' fees. Finally, I agree to accept full responsibility for any activities and/or endeavors in which I participate that are not related to the above-stated activity, including but not limited to, social interactions in the city of Greensboro, any and all morning and evening activities not sponsored by the university or its agents, and any actions I take preceding, during, and after such above-mentioned activity that are beyond the scope of that activity. Participant's Signature Please print name: Date I I '-----'----- A Land-Grant University and A Constituent Institution of the University of North Carolina Memorial Union' 1601 East Market Street- Greensboro, NC (336) Fax (336)

7 North Carolina A&T State University Photo Release I grant permission to the Office of Summer Sessions and Outreach, on behalf of North Carolina A&T State University and its agents or employees, to use photographs taken of me on the date and at the location listed below for use in university publications such as recruiting brochures, newsletters, and magazines, and to use the photographs on display boards, and to use such photographs in electronic versions of the same publications or on University web sites or other electronic form or media, and to offer them for use or distribution in other non-university publications, electronic or otherwise, without notifying me. I hereby waive any right to inspect or approve the :fmished photographs or printed or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the photograph. I hereby agree to release, defend, and hold harmless the North Carolina A&T Board of Directors, on behalf of North Carolina A&T State University and its agents or employees, including any :fmn publishing andlor distributing the :fmished product in whole or in part, whether on paper or via electronic media, from and against any claims, damages or liability arising from or related to the use of the photographs, including but not limited to any misuse, distortion, blurring, alteration, optical illusion or use in composite form, either intentionally or otherwise, that may occur or be produced in taking, processing, reduction or production of the finished product, its publication or distribution. I am 18 years of age or older and I am competent to contract in my own name. I have read this release before signing below, and I fully understand the contents, meaning and impact of this release. I understand that I am free to address any specific questions regarding this release by submitting those questions in writing prior to signing, and I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release. Location of Photo Date Name (please print) Signature Signature of guardian if under 18 years of age