Registration Form Penn State Weather Camp June 14 19, 2015 Penn State Advanced Weather Camp June 21 26, 2015

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1 Registration Form Penn State Weather Camp June 14 19, 2015 Penn State Advanced Weather Camp June 21 26, 2015 TO BE COMPLETED BY PARENT OR LEGAL GUARDIAN. Date of Program Please print in ink or type, and be careful not to skip any sections of this form, as all sections are required for registration. You must also complete the Penn State Youth Program Health Services Medical Treatment Authorization form (attached). This form may be copied for additional registrations. Payment, in full, must accompany this form. Return to Penn State no later than Sunday, May 24, STUDENT INFORMATION [ ] Male [ ] Female Last name First name Middle initial Birth date (month/day/year) Age Home mailing address (no. and street, or box no.) City State ZIP code Country Home phone no. How did you learn about Penn State Weather Camp? [_] Website [_] Teacher [_] Other Applicant s Social Security no.* or Penn State ID no.* *The Social Security number (SSN) you provide for enrollment purposes, or when requesting specific services, will be used by the University to verify your identity for official record keeping and reporting. If you choose not to supply your SSN, certain services such as transcripts, enrollment verification, tax reporting, and financial aid may not be available to you, and Penn State cannot guarantee a complete academic record for you. Your SSN will be stored in a central system and used only as a primary source to identify you within the Penn State system; the Penn State ID will be used as the primary identifier ci-0043 Page 1 of 5

2 PARENT/LEGAL GUARDIAN INFORMATION Parent s/legal Guardian s last name First name Parent s/legal Guardian s address Penn State will use this address to communicate logistical information regarding the program. Daytime phone no. Home phone no. Cell phone no. Camper Pickup: Name of person who will be picking up the student. Name Phone no. Relationship to participant Special dietary needs/accommodations (if none, leave blank): Student s grade next fall (circle one): [OPTIONAL] Optional: T-shirt size: [ ] S [ ] M [ ] L [ ] XL [ ] XXL Do you wish to be put on a waiting list if the program is full? [ ] Yes [ ] No Roommate preference (One name only; the roommate must also complete and mail in a registration form naming you as his/her preferred roommate.): Release I/We, the undersigned, individually and as parent(s) or legal guardian(s) of, a minor, ask that he/she be admitted to participate in this camp sponsored by The Pennsylvania State University. In consideration of such admission, I/we do hereby agree to release, discharge, and hold harmless The Pennsylvania State University, its officers, agents, and employees of and from all causes, liabilities, damages, claims, or demands whatsoever on account of any injury or accident involving the said minor arising out of the minor s attendance at the camp or residence in University housing, or in the course of activities held in connection with the camp. Additionally, I authorize Penn State Conferences and Institutes to photograph, videotape, and/or audiotape my child in promotion of the University's youth programs. I/We have reviewed the Standards of Conduct (found on the Fee and Registration page) with my child, who agrees to follow this code. Signature (At least one is required to complete registration.) _ Parent s/legal Guardian s signature Date ci-0043 Page 2 of 5

3 Scholarships If you cannot afford the registration, you may be eligible for a scholarship. If you would like to be considered for a scholarship, please complete the following information and submit a 100-word handwritten essay (sorry, no typed or computer-produced essays) on this topic: Why I want to go to the Penn State Weather Camp. Attach the essay to your registration form. Deadline: Saturday, February 28 [_] Yes, please consider me for a scholarship for: [_] Financially disadvantaged students [_] Underrepresented students [_] My 100-word, handwritten essay is attached. Even when applying for a possible scholarship, it is recommended that you pay the registration fee to secure a spot as the camps do fill quickly. Enroll the camper in: [ ] Weather Camp (June 14 19, 2015) [ ] Advanced Weather Camp (June 21 26, 2015) Registration Fee [ ] $849 residential fee per participant Method of Payment Your payment, in full, must accompany your registration form. The Pennsylvania State University s federal ID number is [ ] Enclosed is a check or money order for the amount indicated, payable to The Pennsylvania State University. [ ] Credit card guarantee: May be mailed or faxed. [ ] American Express [ ] MasterCard [ ] Visa [ ] Discover Cardholder's name (please print) Cardholder's signature Credit card no. (Credit card charges cannot be processed without signature and expiration date.) / Exp date (mo/yr) BEFORE MAILING, did you remember to: provide parental/legal guardian signature? enclose the Health Services Medical Treatment Authorization form? enclose payment in full? SEND TO: Conferences and Institutes Registration The Pennsylvania State University Box 410 State College PA Fax: ci-0043 Page 3 of 5

4 Penn State University Youth Program Health Services Medical Treatment Authorization This form must be completed and returned before youth camp/program/event enrollment dates in order for youth to be permitted to participate in any camp activities. Personal Information Youth s Last Name First Name Birthdate M F Specify camp your child will be attending Address City State ZIP Home Phone Address Parent/Guardian #1 Parent/Guardian #2 Daytime Phone Daytime Phone Place of employment Place of employment Health Insurance Carrier Policy Number Plan Number Is physician authorization needed? Yes No Name of Family Physician Phone In case of emergency, please notify If neither parent or guardian is available in an emergency, please contact: 1. Phone 2. Phone Health History [Please check and provide approximate dates that camper suffered from allergies and other conditions listed below] Allergies Hay Fever Bee/Wasp Stings Insect Stings Penicillin Peanut Other Food/Drugs: Other Asthma Diabetes Convulsions Concussion Behavioral/Emotional Other: Date of most recent tetanus immunization: Please list any major past illnesses (contagious and non-contagious): Please list any major operations or serious injuries (include dates): Has the youth ever been hospitalized? Does the youth have any chronic or recurring illness? Is there anything else in youth s health history that the camp staff should know? Are there any activities from which the youth should be restricted? Are there any specific activities that should be encouraged? Does the youth have any special dietary restrictions? NO Yes If YES, explain: Does the youth wear any medical appliances (glasses, contact lenses, orthodonture, etc.)? NO Yes If YES, explain: Will the youth need to take any medication at camp? NO Yes If YES, list of all medications taken regularly: Penn State program officials will not dispense over-the-counter (OTC) or prescription medications to participants. Participants will be allowed to possess and take OTC and prescription medications on their own if permission is granted in writing by the parent(s)/legal guardian(s). Both OTC and prescription medications must be in their original containers and listed above. I hereby authorize the clinical staff of University Health Services or other licensed practitioner of the healing arts, acting within the scope of his or her practice under State law to provide medical care that includes routine diagnostic procedures (e.g., x-rays, blood and urine tests) and medical treatment as necessary to my minor daughter/ son/dependent. I understand that the consent and authorization herein granted does not include major surgical procedures and are valid only during the youth camp/program/event ci-0043 Page 4 of 5

5 In the event that an illness or injury would require more extensive evaluation, I understand that every reasonable attempt will be made to contact me. However, in the event of an emergency and if I cannot be reached, I give my consent for physicians and staff at University Health Services or other licensed practitioners of the healing arts to perform any necessary emergency treatment. I agree to the release of any records necessary for treatment, referral, billing, or insurance purposes to the appropriate medical care provider. I understand that University Health Services does charge for services and that it is my responsibility to pay the bill. As applicable, I am responsible to submit any claims to my health insurance company for reimbursement. I authorize The Pennsylvania State University to receive medical/billing information and submit it to the University s insurance carrier. HIPAA Penn State honors the privacy of the participants in its programs and complies with the national regulations regarding health information. Follow this computer link to the University Health Services Notice of Privacy Practices. I understand that, unless specifically stated otherwise in the Penn State youth camp/program/event literature, The Pennsylvania State University does not provide medical insurance to cover emergency care or medical treatment of my child. Parent's/ legal guardian's name (please print) Date: Signature * Terms and Conditions agreed to via electronic signature Revised: 10/03/ ci-0043 Page 5 of 5