Registration and Information Packet

Transcription

1 Registration and Information Packet Checklist of items to return Registration and Photo Release Form Emergency Contact and Medical Release Form University of Wyoming Research Agreement Form Contact information Jeana Lam-Pickett Casper College 125 College Drive Casper, WY Evert Brown, Ph. D. Casper College 125 College Drive Casper, WY Carolyn Jacobs, NCSD Sponsored by: Board of Cooperative Educational Services

2 Casper Mountain Science School What to bring and what not to bring. Things to bring: Must Have Items: Sleeping Bag Pillow Pants (2 pair, long) Shirts (4, T-shirts and long sleeve) Underwear (as many as you think) Sturdy walking shoes or boots Socks (5 pair) Coat Gloves Personal Medications (to be turned in to staff/teacher) Things NOT to bring: ipod (or anything like it) Candy, Gum, Snacks, etc Knives (including pocket knives) Lighters and matches Electronic Games Optional Items /Suggestions: Rain Gear Work Gloves Jacket Backpack Comfortable Shoes (to wear inside of lodge only) Hat Writing Materials (pens/pencils) Water Bottle Soap Personal Toiletries Towel & Wash Cloth Sunscreen Flashlight (w/ extra batteries) Camera Sunglasses Sweater Shorts Jeans Sleepwear Extra Pair of Shoes (in case one gets wet) Realize that you will be outside most of the time. This list is not meant to encourage participants to purchase new things. Please use existing clothing if possible. If you are unable to locate needed items on the list, please contact your teacher. We might be able to help you get what you need. Label all your stuff with your name. Pack Light - you may have to haul it some distance to your cabin. Don t bring extra stuff. It can get cold up on the mountain. Please bring WARM clothing. Warm shoes and a cold weather sleeping bag are essential. Keep this Page

3 Casper Mountain Science School Registration Forms are due 15 days prior to the session you plan to attend. Course # CMSV 3500 For office use only Date received Date completed Section # Student legal name: M / F (circle one) Last First Middle Date of birth: Age: SSN: / / Mailing address: (Please provide complete information to ensure delivery) City: State: Zip: Session Date: Fall Semester: Session # Dates Spring Semester: Session # Dates Other : Session # Dates School currently attending: School city/school district: Science teacher: Current grade: Parent/guardian: Address: (If different than above) Parent s Phone: (h) (w) (c) (parent s): Student s Ethnic Origin (voluntary information) American Indian African American Hispanic Caucasian Asian Other Student s Signature: Date: By checking this box I acknowledge that the application has been correctly completed and I endorse my child s participation at the Casper Mountain Science School. Parent/Guardian Signature: Date: Important Information Photo Release As parent or guardian, I understand that when participating at Casper Mt. Science School, my child will be photographed for print, video, or electronic imaging. I understand that the images may be used in promotional materials, new releases, and other published formats for either Casper Mt. Science School, Casper College, University of Wyoming Casper College Center and/or Natrona County School District. I acknowledge that the images will be the sole property of Casper Mt. Science School and I waive any right to receive compensations for the use of said photographs and video. Parent/Guardian Signature: Date: Questions? Contact: Jeana Lam-Pickett at or jpickett@caspercollege.edu Return this Form

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5 Casper Mountain Science School Emergency Contact and Medical Information Student legal name: M / F (circle one) Date of birth: Age: Students SSN: Parent/guardian: Parents SSN: Parent s Phone: (h) (w) (c) Address: (Please provide complete information to ensure delivery) City: State: Zip: Alternate Emergency Contacts Primary emergency contact Phone: (h) (w) (c) Address: City: State: Zip: Secondary emergency contact Phone: (h) (w) (c) Address: City: State: Zip: Medical Information Physicians name: Physicians phone: Please list any required medications, allergies, and special health considerations. We can accommodate special diets if we know about them ahead of time. I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be preformed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached in the case of an emergency. Student s signature: Date: Witness signature: Date: Please return signed and witnessed form to: Casper Mountain Science School Please note: in order to provide treatment, Wyoming Medical Center requires the social security number of both the parent/guardian an child. Return this Form

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7 Project Title: An investigation into place-based learning at Casper Mountain Science School Researchers: Dr. Jennifer Forrester, Assistant Professor of Elementary Education, Departments of Elementary Education and Educational Studies, University of Wyoming, Phone Number (307) , Dr. Jason Katzmann, Assistant Professor of Secondary Science Education, Department of Secondary Education, University of Wyoming, Phone Number: (307) , Dear Parent/Guardian: As you are aware, your son or daughter will be attending a science residency program at Casper Mountain Science School (CMSS). In order to evaluate the effectiveness of CMSS and the impact this experience has on your child we are asking for permission for your child to participate in our research study. This empirical research study explores the impact of place-based learning on k 12 grade students science self-efficacy, science content knowledge and students perceptions of environmental conservation and stewardship. Undergraduate and graduate students will also be invited to participate in this study. Place-based education provides participants with opportunities to interact with the ecological and human communities in which they exist. Such opportunities are available for people in the state of Wyoming through the Casper Mountain Science School. This project seeks to understand the impact of participating in place-based education experiences at the Casper Mountain Science School on K-12 students and undergraduate and graduate students. Your son or daughter s participation will involve being interviewed and videotaped by researchers while at CMSS. The interview will reflect on their CMSS experience and the video recordings will follow whole groups in the field. This project seeks to understand the impact of participating in place-based education experiences at the Casper Mountain Science School on the undergraduate and graduate professors in addition to the k 12 students. Your son or daughter s participation will involve being interviewed by researchers while at CMSS, being videotaped while in the field with students and being interviewed at a later date in which we will reflect on their CMSS experience. The interviews will take approximately 30 minutes before their CMSS experience and 30 minutes at the end of their CMSS experience. Observations and video recordings in the field will not require any interaction with the research team. Each field team will be observed a minimum of 2 hours per day and a maximum of 9 hours in one day. These interviews and observations will be conducted during their CMSS experience. Four students will be randomly selected to participate in an additional interview in which they will be questioned regarding their thoughts about spending time outside and conservation. University of Wyoming/Casper College Center 125 College Drive Room 163 Casper, WY Teacher will Return this Form

8 Participation is voluntary. All responses on the survey and interviews are confidential. Confidentiality will consist of replacing your child s name with a pseudonym, the link between your child s name and pseudonym will only be known by the research team. Only the research team will have access to the raw data. Interviews will be audio recorded and transcribed. Data will be stored in a locked filing cabinet in a secure office. Interviews, audio and video recordings will be stored for a period of seven years at which time all data will be destroyed. The risk of participating in this research is no greater than those risks ordinarily encountered in daily life or during the performance of routine physical and psychological examinations or tests. These risks would include interacting with a person whom your child is not familiar, responding to questions they do not know the answer to, or dealing with an uncomfortable situation. You may decide to withdraw your son or daughter from this study and if they begin participation you may still decide to stop and withdraw them at any time. Your decision will be respected and will not result in loss of benefits to which you or your child is otherwise entitled. Signing and returning this form with your registration forms for CMSS implies your consent to participate in the study. If you have any concerns about your selection or treatment as a research participant, please contact the Institutional Review Board Administrator, Dorothy Yates: Room 308, Old Main, 1000 East University Ave., Department 3355, University of Wyoming, Laramie, WY 82071; or by phone Please feel free to phone or me if you have any questions or concerns about this research and please retain one copy of this letter for your records. Sincerely, Jason Katzmann, Ph.D. Assistant Professor Secondary Science Education University of Wyoming/Casper College Center Jennifer Forrester, Ph.D. Assistant Professor Early Childhood and Elementary Education and Educational Studies University of Wyoming/Casper College Center As parent or legal guardian, I hereby give my permission for (print child s name) to participate in the research described above. I understand that my child s participation is voluntary and can be withdrawn at my discretion. Date: My son/daughter may be videotaped during their CMSS experience, please check My son/daughter may be audio recorded during interviews, Please check My son/daughter may participate in the extra interview about conservation/outdoors, Please check Parent or Legal Guardian s signature: University of Wyoming/Casper College Center 125 College Drive Room 163 Casper, WY 82601