Fillable 2019 Mancamp Wwos Release Form (University of Wyoming)

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2019 Mancamp Wwos Release Form (University of Wyoming)

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UNIVERSITY OF WYOMING YOUTH PROGRAM
REGISTRATION/GENERAL INFORMATION FORM
PROGRAM
NAME/LOCATION/DATES: MANCAMP & Wyoming Women of Song - October 25 & 26, 2019
PARTICIPANT
I
NFORMATION
Participant Name
Date of Birth Grade as of 9/1/19 Gender: M F
Please indicate here ____ if Participant needs an accommodation to participate. Please provide details on the Medical
Information Form. Formal
accommodations may be requested by contacting Philip Moline (pmoline@uwyo.edu) by
October 8, 2019
PARENT/GUARDIAN CONTACT INFORMATION
First Parent/Legal Guardian Name
Street Address
City State Zip
Home Phone Work Phone
Cell Phone Email
Second Parent/Legal Guardian Name
Street Address
City State Zip
Home Phone Work Phone
Cell Phone Email
EMERGENCY CONTACT INFORMATION
Provide 2 people who may be called in the event we cannot reach either parent/guardian:
Emergency Contact #1 Name Home Phone # Work Phone # Cell Phone # Relation
Emergency Contact #2 Name Home Phone # Work Phone # Cell Phone # Relation
In the case
the Participant becomes ill, violates any program policy, or for any other reason must leave the Program, Program
Staff will contact the parent/guardian listed first and then the parent/guardian listed second. If the parent/guardian is unable to be
reached, the Participant’s emergency contact will be notified. It is the responsibility of the parent/guardian or emergency contact
to arrange for the participant to be picked up as soon as possible.
In the event of an emergency impacting the entire Program, Program Staff will contact the individuals listed above in the same
order and provide specific information and instructions based on the nature of the emergency.
COMMUNICATION
If an
emergency arises and you need to communicate with a Participant during the Program you may contact Philip Moline at
307-851-4385 (personal cell phone to be used only in emergency).
Non-emergency communications to the Participant during the Program may be made by contacting Fine Arts Outreach by
phone at 307-766-5139
Any concerns regarding the Program, reports of violations of the University’s Policy on Minors, or any other concerns should
be addressed to Philip Moline at pmoline@uwyo.edu or 307-766-5139.
Participant Name Parent/Guardian Name
___________________________
Participant Signature Parent/Guardian Signature ________________________
Date Date __________________________________________
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UNIVERSITY OF WYOMING YOUTH PROGRAM
RULES AND DISCIPLINARY PROCEDURES
PROGRAM NAME: MANCAMP & Wyoming Women of Song
PROGRAM RULES:
1. The possession, distribution, or use of alcohol or drugs is prohibited.
2. Fireworks, firearms, guns, knives, archery equipment and other weapons are prohibited.
3. The operation of motor vehicles by Minors is prohibited while attending and participating in the Program. Permission
for a Minor to drive from the Program at the Program’s conclusion must be authorized by the parent/legal guardian.
Use of bicycles, skateboards, rollerblades, skates and other related items is discouraged and any use must be in
accordance with University Policy. Hover boards are prohibited.
4. Participants are to remain on campus for the duration of the program unless program activities require otherwise. If a
participant needs to leave campus for some reason, Program Directors must receive prior written permission from the
parent or guardian, and grant specific permission.
5. Participants must attend all Program activities including workshops, classes, and planned social or recreational
activities.
6. No violence, including sexual abuse or harassment, will be tolerated.
7. Hazing of any kind is prohibited. Bullying including verbal, physical, and cyber bullying are prohibited.
8. No theft of property, regardless of owner, will be tolerated.
9. Use of tobacco products and smoking instruments including electronic cigarettes and vaporization devices will not be
tolerated by participants. Smoking is prohibited in all University buildings.
10. Misuse, damage, tampering, moving, modifying, or theft of University property is prohibited. Charges will be assessed
against those participants who are responsible for damage or misusing University property.
11. Misuse, damage or theft of the property of others is prohibited.
12. The inappropriate use of cell phones, cameras, imaging, and digital devices is prohibited including use of such devices
in showers, restrooms, or other areas where privacy is expected by participants.
DISCIPLINARY PROCEDURES:
Each participant has a
reasonable expectation to enjoy a positive program experience. Therefore, the misbehavior of one
participant, or a group of participants, should not be permitted to impact negatively on the program experience of others. Most
programs are short in duration, so prompt action is required when problems occur. Parents and participants should be aware of
the rules and disciplinary policy.
First Offense: Participants failing to adhere to Program Rules, assisting or encouraging others to break Program Rules, or
exhibiting bad or disruptive behavior, will be warned by Program Staff.
Second
Offense: Subsequent misconduct will result in a discussion between the Program Staff and Participant and Program
Staff will co
ntact the Participant’s parent/guardian.
Third Offense: Subsequent misconduct will result in expulsion from Program.
ANY OF THE STEPS OUTLINED ABOVE MAY BE OMITTED OR REPEATED AT THE DISCRETION OF PROGRAM
STAFF. PARTICIPANTS DISMISSED FROM PROGRAM FOR DISCIPLINARY REASONS WILL NOT RECEIVE A
REFUND OF ANY FEES PAID TO ATTEND PROGRAM.
This procedure is intended to provide a reasonable and consistent method for dealing with the type of behavior that can be
disruptive
to a program or other University activities are functions, but is not so egregious as to warrant immediate dismissal
from the program. It in no way precludes immediate dismissal from the program for more serious disciplinary
problems or violations of campus or program regulations. A serious disciplinary problem is defined as one in which the
program staff determines that a child is engaging in inappropriate behavior that includes, but is not limited to the
following: actions which put the participant, other participants, or program staff member’s safety in jeopardy; physical,
emotional, or electronic harassment/harm against self, program staff or fellow program participants; inflicting physical or
emotional harm on self or others, vandalism or destruction of University property; theft of University property or the property
of another participant; consistently disrupting the program or other programs or University functions; possession of alcohol,
drugs, or weapons; fighting; or sexual harassment.
Disciplinary decisions are solely in the discretion of Program Staff and the decision of Program Staff is final.
With my/our signature below
I/we understand the disciplinary procedures described above. I/we understand failure to demonstrate proper conduct
during the Program may result in early dismissal from the Program without any refund of fees paid to attend. I/we
pledge to abide by all Program Rules and to exercise good behavior.
Participant Name
Participant Signature
Date
Parent/Guardian Name
Parent/Guardian Signature
Date
UNIVERSITY OF WYOMING YOUTH PROGRAM
MEDICAL INFORMATION AND RELEASE FORM
PROGRAM NAME: MANCAMP & Wyoming Women of Song
Completion of this form by a parent/guardian is required before a minor can participate in the Program. The information
requested on this form is intended to help inform Program Staff of any pre-existing medical conditions. If Participant has a
pre-existing medical condition, participation in any strenuous activities or recreational time may not be recommended.
This information will be kept in strict confidence and will only be shared with your permission. The University
requests the information below so that, in case of emergency, we will have accurate information so that we can
provide and/or seek appropriate treatment for Participant. You are accountable for providing an accurate medical history.
Please answer all questions. Incomplete forms will be returned to you for the missing information. Attach any specific
recommendations from your physician to this form. Final determination about whether to participate is the
responsibility of the Participant, Participant’s parent/guardian, and Participant’s physician. If Participant has any
health issue that is not requested below, but which you think is important, please include that information. It is
recommended that you consult with a physician prior to participating in this Program. If you are uncertain about any
preexisting medical
condition
s, it is your responsibility to consult with your own physician prior to participating.
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Date of Birth Gender: M F
First Parent/Legal Guardian Name
Street Address
City State Zip
Home Phone Work Phone
Cell Phone Email
Second Parent/Legal Guardian Name
Street Address
City State Zip
Home Phone Work Phone
Cell Phone Email
Emergency Contact #1 Name Home Phone # Work Phone # Cell Phone # Relation
Emergency Contact #2 Name Home Phone # Work Phone # Cell Phone # Relation
MEDICAL INFORMATION
Physician Name: _______________________________________________________________
Physician Address: _____________________________________________________________
Physician Telephone: ____________________________________________________________
Date of most recent tetanus toxoid immunization: _____________________________________
Do you have health/accident insurance? YES NO
Participant Name
GENERAL INFORMATION
Insurance Company Name: _____________________________________________________________________________
Insurance Company Claim Address: ______________________________________________________________________
Insurance Policy #: _____________________________________________________________________________________
Does participant have any limiting medical conditions or chronic/recurring illnesses that would limit camp participation?
YES NO If yes, identify and explain:
Is participant currently taking medication that may interfere with ability to safely participate in Program?
YES NO If yes, please indicate the medication and the condition being treated.
Does participant have a history of allergies or reactions to medications
, insect stings, plants, food, or
other substances?
YES
NO
If yes, please explain:
Does
participant have a history of, or currently suffer from, medical condition(s) of which we need to be aware?
YES
NO
If yes, please explain:
Does Participant
have any behavioral condition(s) of which we need to be aware?
Y
ES
NO
If
yes, please explain:
Does the Participant
w
ear a
ny medical appliances (glasses, contacts, orthodontia, etc.)?
YES NO If yes, please explain:
Except to the extent I have requested a formal accommodation by the University, which requires a separate interactive process, I
understand that by reveali
ng or disclosing the above medical information I am providing critical information but it will
not be used by the University to determine the Participant’s ability to participate safely in the Program activities. I
understand that, if Participant chooses to participate in activities, he/she do so voluntarily and of his/her own accord and the
final decision regarding participation is solely the responsibility Participant, Participant’s parent/guardian, and any medical
or other advisor Participant engages in assisting what that decision.
AUTHORIZATION FOR CARE
As the parent/guardian of the Participant I understand the University is not equipped to make mental or medical health
diagnoses/determinations or provide mental or medical health care (other than any pre-arranged accommodations) during the
Program and any care needs that arise during the Program may require the Participant discontinue attendance at the Program to
seek appropriate care. In cases where emergency medical attention is necessary, parents/guardians/emergency contacts will be
contacted for approval when possible. However, I hereby grant permission for the University to give or authorize emergency
medical treatment to my child during his/her participation in the Program if, in the sole discretion of the University, such care is
necessary. I understand and agree that the University assumes no responsibility for any injury or damage, which might arise out
of or in connection with such authorized emergency medical treatment. I will assume the financial responsibility for any cost of
care for my child that may occur during the Program.
As a Participant/parent/guardian I understand and acknowledge that failure to disclose relevant information may result in harm
to Participant and/or others during this Program. By signing my name I represent and warrant that I have provided all important
information pertaining to Participant’s medical, mental and physical condition and that the information provided is accurate and
complete. I agree to notify the University of any change in the Participant’s mental, physical or medical condition prior to or
during the Program.
Except to the extent I have requested a formal accommodation by the University, which requires a separate interactive process, I
understand that by revealing or disclosing the above medical information I am providing critical information but it will not
be used by the University to determine the Participant’s ability to participate safely in the Program activities. I understand
that, if Participant chooses to participate in activities, he/she do so voluntarily and of his/her own accord and the final decision
regarding participation is solely the responsibility Participant, Participant’s parent/guardian, and any medical or other advisor
Participant engages in assisting what that decision.
Participant Name ___________________________ Parent/Guardian Name ________________________
Participant Signature ________________________ Parent/Guardian Signature ________________________
Date __________________________________________ Date _________________________________________
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UNIVERSITY OF WYOMING YOUTH PROGRAM
SELF-ADMINSITRATION OF MEDICATION FORM
PROGRAM NAME MANCAMP & Wyoming Women of Song
Participant Name
Parent/Legal Guardian Name
If at all possible, medication should be administered at home. Medications will be allowed at the Program only when failure to
take such medicine would jeopardize the health of a Participant and he/she would not be able to attend the Program if the
medicine were not made available.
Legal prescription and over-the-counter medications, including medications for conditions such as food, drug or insect allergies,
diabetes, asthma, or epilepsy may be brought to the Program under the condition that the participant can self-manage care and
delivery of the medication. All medications (prescription and over-the-counter) must be in the original product packaging and
clearly labeled with the Participant’s name. Prescription medication(s) must also include a label with the medication’s name and
dosage instructions, as well as the prescribing physician’s name and telephone number. Containers must hold only the amount
required for the time the Participant will be attending the Program.
List the specific prescription or over-the-counter medication(s) the Participant is bringing to the Program, the reason for the
medication, and the daily dosage, times taken and other relevant administration information below:
Medication Name
Diagnosis/Reason(s) for Medication
Daily Dosage/Time(s) Taken/Administration
1.
2.
3.
4.
All medications will be kept securely locked. Access to all medications will be limited to approved Program Staff. The need for
emergency medication may require that a Participant carry the medication on his/her person or that it be easily accessed (i.e.
inhalers, EPI-pens, insulin injections). Program staff will NOT purchase or administer medications of any type (prescription or
over-the-counter) for a participant of any age. Program staff may monitor the self-administration of medications. It is NOT
permissible for a participant to share any medications with any other participants. It is the responsibility of the parent(s)/legal
guardian(s) to be sure that the participant’s medications brought to the Program are not left behind at the end of the Program.
Failure to do so will result in the medications being destroyed after the Participant’s last day at the Program. Absolutely no
medications will be returned via mail regardless of circumstance.
I authorize and recommend self-medication by my child for the above medication(s). I affirm that my child has been
instructed in the proper self-administration of the prescribed medication by his/her physician. I affirm that my child
has been instructed in the proper self-administration of the over-the-counter medication by
me or by his/her physician. I will indemnify and hold harmless the Program Staff, the University of Wyoming,
its Board of Trustees, Administration, Faculty, Staff, Student Leaders, and all other officers, directors, employees and
agents against any claims that may arise relating to my child’s self-administration of prescrib
ed medication(s).
Parent/Guardian Name ________________________________________________________________________
Parent/Guardian Signature ______________________________________________________________________
Date ________________________________________________________________________________________
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UNIVERSITY OF WYOMING YOUTH PROGRAM
RELEASE, ASSUMPTION OF RISK & AGREEMENT TO HOLD
HARMLESS
PROGRAM NAME: MANCAMP & Wyoming Women of Song
PROGRAM LOCATION: Buchanan Center for Performing Arts
PROGRAM DATES: October 25-26, 2019
I am in receipt of a Program itinerary and description of the activities of the Program referenced above. I, the
undersigned, wish for my child, identified as the Participant below, to participate in all of the activities of the above
referenced Program on the dates listed above and in consideration of my child being allowed to participate I agree as
follows:
I am aware that while participating in the Program there are dangers, hazards and inherent risks, both known and
unknown, to which my Child may be exposed and participating involves a risk of injury or injuries ranging from
minor injuries such as bruises, cuts or scrapes, to serious injuries such as paralysis or even death. I am aware that such
an injury can limit my child’s future life activities, including future earning capacity. I am aware that there are also
risks of property damage or loss.
I hereby grant permission for the University to give or authorize emergency medical treatment, if necessary, and such
action by the University shall be subject to the terms of this Agreement. I understand and agree that the University
assumes no responsibility for any injury or damage, which might arise out of or in connection with such authorized
emergency medical treatment.
In consideration of the University of Wyoming, providing my child with the opportunity to participate, I hereby
assume all the associated risks and agree to hold the University of Wyoming, its trustees, officers, employees,
agents, representatives, instructors, and volunteers and the State of Wyoming harmless from any and all liability,
actions, causes of action, debts, claims, or demands of any kind and nature whatsoever which may arise by or in
connection with my child’s participation. The terms hereof shall serve as a release and assumption of risk for
myself, my child, and my child’s and my heirs, estate, executor, administrator, assignees and for all members of
our family.
I have read the above statement and fully understand the contents, consequences and implications of signing
this document.
Participant Name _______________________________________________________________________
Participant Address _____________________________________________________________________
Parent/Guardian Name __________________________________________________________________
Parent Guardian Signature _______________________________________________________________
Date __________________________________________________________________________________
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UW Department of Music
Dept. 3037 • 1000 E. University Avenue • Laramie, WY 82071
(307) 766-5242 • fax (307) 766-5326
MODEL RELEASE
I, _______________________ _________________ (______), do hereby
Print full name Age *
authorize the University of Wyoming, its agents, successors, and assigns, to use and reproduce
photograph(s) in which I appear in official UW publications, and I waive any right that I may have
to inspect and approve said photograph (or any copy that may be used in connection therewith) or
to receive compensation for the use of said photograph.
_____________________________________ ______________________________________
Sign full name Parent or Guardian
______________________________________
Street or box number
______________________________________
City, state, zip code
_______________________________________
Phone
_______________________________________
Date
Sovereign Immunity. The University of Wyoming does not waive its sovereign immunity or its governmental immunity and
fully retains all immunities and defenses provided by law.
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2019 Mancamp Wwos Release Form (University of Wyoming)

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Completed 20 July 2020

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