Fill - Free fillable Camps Clinics Minors On Campus Form (Elizabethtown College) PDF form

Elizabethtown College

Facilities Management – Special Events & Summer Programs

One Alpha Drive, Elizabethtown, PA 17022

Phone (717) 361-1203

Working with Minors Packet

The following six (10) page Registration of Minors on Campus Form must be

completed no later than thirty (30) days prior to the start of the Clinic/Program at

Elizabethtown College, and returned to:

Elizabethtown College

Special Events & Summer Programs

One Alpha Drive

Elizabethtown, PA 17022

OR

Electronically to: SESP@etown.edu

Please direct questions to the Special Events & Summer Programs Office phone

717.361.1418.

Elizabethtown College

Facilities Management – Special Events & Summer Programs

One Alpha Drive, Elizabethtown, PA 17022

Phone (717) 361-1203

Registration of Minors on Campus Form

Covering Minor Participation in College Programs and Events

INSTRUCTIONS: Under the Elizabethtown College Policy Regarding Minors on Campus, if a College program or event involves the

participation of minors, this form must be completed with the required signatures and submitted to the Director of Human Resources,

no later than 30 days prior to the start of the Program or Event. College Program/Event organizers will be responsible for

communicating with the high school or minor associated group or individuals and providing them with a copy of the College’s Policy

Regarding Minors on Campus and the appropriate Release and Consent Forms included in the Working with Minors Packet. Please

contact the Director of Human Resources or the Human Resources Office at 717-361-1406 with any questions concerning this form or

the registration process.

DEFINITION OF A MINOR—A minor under Pennsylvania law, is an individual under the age of 18 years. For the purposes of this

policy, minors on the College campus are children under 18 years of age participating in programs, internships, camps or activities

on campus, whether or not it is a college sponsored program or through a third party.

I. GENERAL PROGRAM INFORMATION

Name of Department Organizing the Program/Event:

Dept.:______________________________, Elizabethtown College, One Alpha Drive, Elizabethtown, PA 17022

Name:________________ ____Email:____________________________ Phone:_________________________

Name of Program/Event:

Clinic:

Name of Director:

Email address: Phone Number:

Dates of Program/Event:

How will the Minors Participate in the Program/Event?

_____________________________________________________________________________________

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Elizabethtown College

Facilities Management – Special Events & Summer Programs

One Alpha Drive, Elizabethtown, PA 17022

Phone (717) 361-1203

Who will be the “Authorized Adults” Supervising or Accompanying the Minors while participating in the

Program/Event? (Please list below, or use a separate sheet).

Authorized Adult—An authorized adult is an adult, age 18 or older, who is authorized, pursuant to this policy, to supervise, or

otherwise have Direct Contact with, minors participating in a Program. All College employees, students, independent contractors, and

volunteers (including but not limited to, Faculty, Staff, Students, Tutors, Instructors, Supervisors, Coaches, Camp Counselors, Program

Directors, Chaperones, Volunteers, Third Party Contractors, Vendors, and Temporary/Seasonal Workers) acting as authorized adults

must be in compliance with the requirements of the provisions of this Policy entitled “Individuals Acting as Authorized Adults.” Although

a parent or legal guardian may supervise their own minor children and their guests who are minors while visiting the campus or using

campus facilities, a parent or legal guardian may not act as an Authorized Adult in a Program (including one in which his or her child

participates) unless they are in compliance with the requirements outlined below under “Individuals Acting as Authorized Adults.”

Authorized Adults are considered Required Reporters.

II. COMMUNICATION PLAN

Please provide below or on a separate sheet a description of Communication Plan to be followed by the program.

The Communication Plan must include:

• A procedure for obtaining and maintaining contact information for participants’ parents/legal guardians, as well as

emergency contacts in the event the parents/guardians are unavailable;

• A procedure for notification of all participants’ parents/legal guardians in the event of an emergency; and

• A procedure for parents and guardians to follow to contact program personnel and/or their child during program hours.

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Elizabethtown College

Facilities Management – Special Events & Summer Programs

One Alpha Drive, Elizabethtown, PA 17022

Phone (717) 361-1203

III. MEDICAL EMERGENCY PLAN

Please provide below or on a separate sheet an outline of the Medical Emergency Plan to be followed by the Program. The

Medical Emergency Plan shall include:

• A procedure for obtaining and maintaining (i) authorization from all participants’ parents/legal guardians to transport

program participants to local hospitals as deemed necessary; and (ii) authorization for emergency medical treatment in the

event the parents/legal guardians or their designated emergency contact are not available;

• A procedure for obtaining and maintaining disclosures of any allergies or other medical condition or physical limitation that

might impact participation in the Program; and

• A procedure to administer medication to program participants as necessary during program hours.

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Elizabethtown College

Facilities Management – Special Events & Summer Programs

One Alpha Drive, Elizabethtown, PA 17022

Phone (717) 361-1203

IV. SUPERVISION PLAN

Please provide below or on separate sheet a description of the Supervision Plan to be followed by the program.

Please note that the Policy Regarding Minors on Campus prohibits any unobserved, unsupervised one-on-one contact between a

minor and any Authorized Adult. A Supervision Plan must specify:

• The person having responsibility over all Authorized Adults serving in the Program;

• The proposed ratio of participants to Authorized Adults;

• The proposed number of Authorized Adults over 21;

• The breakdown of Authorized Adults by category of employees, students and volunteers; and

• Curfew, rules pertaining to any visitors, and limitations of use of free time in the event the Program involves any overnight

stays.

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Elizabethtown College

Facilities Management – Special Events & Summer Programs

One Alpha Drive, Elizabethtown, PA 17022

Phone (717) 361-1203

V. TRANSPORTATION PLAN

Please provide below or on an attached sheet a description of the Transportation Plan to be followed by the program.

The Transportation Plan must include:

• A procedure for the pick-up and drop-off of participants, specifying times and locations;

• A procedure to obtain written permission from a parent or legal guardian in the event any participant is to be released to

any person other than his or her parents or legal guardians; and

• A description of any transportation of participants to be provided by the program, specifying the type of vehicle, and

drivers. Under no circumstances shall an Authorized Adult be permitted to be alone with a minor in a car or other vehicle.

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Elizabethtown College

Facilities Management – Special Events & Summer Programs

One Alpha Drive, Elizabethtown, PA 17022

Phone (717) 361-1203

Signatures_________________________________________________________________________

Program/Event Organizer: ________________________________________ _ Date ________________

Elizabethtown College:

Special Events & Summer Programs: ______________________________________________ Date ________________

Director of Human Resources: ____________________________________________ Date ________________

Copies To:

Program/Event Organizer

SESP, as appropriate

Protection of Minors File

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Elizabethtown College

Facilities Management – Special Events & Summer Programs

One Alpha Drive, Elizabethtown, PA 17022

Phone (717) 361-1203

Working with Minors – SAMPLE FORM (We recommend you create a similar form

which will authorize you to obtain background information on the camp/conference

authorized adults).

Criminal Background Check Information & Inquiry Release For Students and Volunteers

Elizabethtown College’s Policy Regarding Minors on Campus provides that employees, students, volunteers, and third party

contractors who are expected to work directly with minors are required to successfully complete a criminal background screening

prior to beginning any assignment involving minors and to participate in required training. This requirement is fulfilled for staff and

faculty under the College’s Background Checks Policy, and third party contractors are required to screen their own employees

prior to beginning any such assignment.

--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

I understand that I am covered by the Policy Regarding Minors on Campus as a student or volunteer who may be working directly

with minors, and I understand that my consent to such criminal background screening is a condition of my initial and continued

participation in any College program involving minors. I have carefully read the Policy Regarding Minors on Campus and this Consent

and Release Form, and I hereby consent to such criminal background screenings, including those performed by any consumer

reporting agency at the College’s request. This consent will continue to apply throughout the period of my participation in any such

College program to the extent permitted by law.

Reports prepared by a consumer reporting agency based on its criminal background screenings may constitute consumer or

investigative consumer reports as defined in the Fair Credit Reporting Act. Such reports may include federal, state or local criminal

history records or information pertaining to me, and other information concerning my education, qualifications, work experience,

character, general reputation, personal characteristics and/or mode of living. I hereby authorize any consumer reporting agency to

release and disclose, verbally and in writing, these reports and this information to authorized representatives of [camp/conference

name] within the terms of the Policy Regarding Minors on Campus.

I hereby authorize all persons and entities including, without limitation, educational institutions, my current and former employers,

government agencies and police departments, to disclose and provide all relevant records and information requested by a consumer

reporting agency or Elizabethtown College as part of any criminal background screening obtained pursuant to the Policy Regarding

Minors on Campus; and I hereby forever release and discharge (1) Elizabethtown College, (2) any consumer reporting agency that

performs any criminal background screening at the College’s request pursuant to the Policy Regarding Minors on Campus, and (3)

any person or entity including, without limitation, any educational institution, my current and former employers, any government

agency or police department that discloses or provides records or information requested by Elizabethtown College or any consumer

reporting agency as part of a criminal background screening obtained pursuant to the Policy Regarding Minors on Campus

(collectively, the “Releasees”), as well as all of the Releasees’ trustees, directors, officers, employees and representatives, from any

claims, suits, damages, losses, liabilities, costs or expenses arising as the result of or in any way related to their participation in the

performance of any background check, information verification, and/or other action taken pursuant to the Policy Regarding Minors on

Campus, to the fullest extent permitted by law.

I hereby certify that the information I have provided below is true and complete to the best of my knowledge. I understand that if any

such information is materially false or incomplete, it will be sufficient cause for termination of my participation as a student or

volunteer in any Elizabethtown College program covered by the Policy Regarding Minors on Campus, now or in the future. I agree

that this Consent and Release Form, in original, faxed, photocopied or electronic form, will be valid for any criminal background

screening, reports or other purposes under the Policy Regarding Minors on Campus.

Print Full Name ______________________________________________________________ Date of Birth* ___________________________

Social Security # _______________________________________ Driver’s License # ______________________________________________

Maiden Name ____________________________________________ Other Names Used ___________________________________________

Street Address ___________________________________________________________________________________________________________

City _______________________________________________________________ State __________________ Zip _____________________

Signature ____________________________________________________________________ Date ______________________________

*Date of birth is being requested only for the purposes of identification in obtaining accurate retrieval of records and it will not be used for discriminatory

purposes.

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Elizabethtown College

Facilities Management – Special Events & Summer Programs

One Alpha Drive, Elizabethtown, PA 17022

Phone (717) 361-1203

Working with Minors

Adult Participant Information & Waiver Form

The information collected in this form is confidential and will only be shared in a medical emergency. Please complete all fields.

Attendee Information

Participant’s Full Name: __________________________________________________ Address: _____________________________________

City _______________________________________________ State: ________________________ Zip Code: ________________________

Home Phone Number: ___________________________________________ Cell Number: _________________________________________

Emergency Contact Information

(Contact #1) Name: _______________________________________________ Relation to Participant: _________________________________

Home Phone Number: ____________________________________ Cell Phone Number: ___________________________________________

Work Phone Number: ____________________________ Place of Employment: __________________________________________________

(Contact #2) Name: ______________________________________________ Relation to Participant: _________________________________

Home Phone Number: ____________________________________ Cell Phone Number: ___________________________________________

Work Phone Number: ____________________________ Place of Employment: __________________________________________________

Waiver/Release Information

I understand and agree that I am responsible for arranging my own health, accident, and liability insurance, and that no such insurance is

provided by ___________________________________ [insert Conference/Organization] and/or Elizabethtown College.

I hereby authorize the employees and/or agents of _______________________________________ [insert Conference/Organization] and/or

Elizabethtown College, at their sole discretion, to secure such medical advice and/or services as may be deemed necessary for my health and

safety, and I agree to accept full financial responsibility for such advice or services.

RELEASE AND INDEMNIFICATION. FOR MYSELF AND ALL THOSE WHO MAY CLAIM THROUGH ME OR IN MY PLACE, AND IN EXCHANGE FOR

AND IN CONSIDERATION OF ___________________________________________ [insert Conference/Organization] AND ELIZABETHTOWN

COLLEGE PERMITTING ME TO PARTICIPATE IN THIS CONFERENCE AND RELATED ACTIVITIES, I HEREBY ASSUME ALL THE RISKS OF INJURY

ASSOCIATED WITH THIS CONFERENCE AND RELATED ACTIVITIES AND AGREE TO RELEASE, HOLD HARMLESS, AND INDEMNIFY

___________________________________________________________________ [insert Conference/ Organization] AND ELIZABETHTOWN

COLLEGE, AND THEIR OFFICERS, AGENTS, AND EMPLOYEES FROM ANY AND ALL LIABILITY, ACTIONS, CAUSES OF ACTION, NEGLIGENCE,

CLAIMS OR DEMANDS OF ANY NATURE WHATSOEVER THAT MAY ARISE BY OR IN CONNECTION WITH MY PARTICIPATION IN THIS

CONFERENCE AND RELATED ACTIVITIES.

In signing this document I acknowledge that I am 18 years of age or older, that I have read it, that I understand it, that I have signed it

knowingly and voluntarily, and that I accept and intend to be legally bound by its terms.

Date: ____________________________________ Signed: _____________________________________________________________

Name Printed: ____________________________________________________________

This form must be completed, printed, and mailed, emailed (scanned as a PDF file), or faxed to the Conference/Camp Director.

Page 8

Elizabethtown College

Facilities Management – Special Events & Summer Programs

One Alpha Drive, Elizabethtown, PA 17022

Phone (717) 361-1203

Working with Minors

Minor Participant Information & Waiver Form

The information collected in this form is confidential and will only be shared in a medical emergency. Please complete all fields.

Attendee Information

Participant’s Full Name: __________________________________________________________ Address: _____________________________

City: _______________________________________________ State: ________________________ Zip Code: ________________________

Home Phone Number: ____________________________________________ Cell Number: _________________________________________

Date of Birth: ___________________________________________________ Gender: ____________________________________________

Emergency Contact Information

(Contact #1) Name: ___________________________________________________ Relation to Participant: _____________________________

Home Phone Number: _________________________________________ Cell Phone Number: ______________________________________

Work Phone Number: _________________________________ Place of Employment: _____________________________________________

(Contact #2) Name: ___________________________________________________ Relation to Participant: _____________________________

Home Phone Number: _________________________________________ Cell Phone Number: _______________________________________

Work Phone Number: _________________________________ Place of Employment: ______________________________________________

Insurance Information

Health Insurance Company Name:

___________________________________________________________________________________________

Policy or Member ID Number: ______________________________________ Group Number: _______________________________________

In whose name is the insurance listed:

________________________________________________________________________________________

Medical Information

Is your child under medical treatment: Yes ________ No ________

List condition(s): __________________________________________________________________________________________________

Please list any medications your child currently takes:

Prescription: ____________________________________________________________________________________________________

Over the counter: _________________________________________________________________________________________________

Can your child self-medicate? ___________________________________________________________________________________________

Please check pain reliever that may be given: Tylenol ________ Ibuprofen ________ Other __________________________

Name of Family Doctor: _________________________________________________ Phone Number: ________________________________

List any physical conditions and explain treatment:

____________________________________________________________________________________________________________________

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Elizabethtown College

Facilities Management – Special Events & Summer Programs

One Alpha Drive, Elizabethtown, PA 17022

P

hone (717) 361-1203

____________________________________________________________________________________________________________________

Please list any pre-existing conditions or medical concern(s) that would limit your child’s participation:

____________________________________________________________________________________________________________________

Medication Permission

______________________________________________ has brought/will bring the following medications with him/her. He/she has my

(name of participant)

permission to use them. He/she may not share them with anyone else.

Medications:

____________________________________________________________________________________________________________

Parent/Guardian Signature: ___________________________________________________________ Date: ____________________________

I, ___________________________________________________, am aware that I may NOT share any medications with other participants.

Participant Signature: ______________________________________________________________ Date: ______________________________

Medical Treatment Authorization

In the event that medical treatment for my child is required, I authorize a representative of ____________________________________[Insert

name of camp/conference] to take my child to be treated at a nearby hospital. I also understand that my insurance is primary if medical

treatment is rendered.

Parent/Guardian Signature: _____________________________________________________________ Date: ______________________

Waiver/Release Information

I

n consideration for the permission granted by _______________________________________________ [insert name of camp/conference] for Minor to

participate in this Event, on my behalf and on behalf of the Minor, and each of my and the Minor’s heirs, executors, and administrators, I hereby waive and release

any and all causes of action, claims, suits, damages, and judgments, in any form whatsoever, arising from or by reason of any and all known or unknown, foreseen

or unforeseen bodily or personal injuries (including death) or property damage, resulting from the Minor’s participation in the Event and related activities, against

Elizabethtown College and ______________________________________________

[insert name of camp/organization], and their employees, administrators, trustees, volunteers, and agents.

IN WITNESS WHEREOF, and intending to be legally bound, I have executed this document below.

Signature of Parent/Legal Guardian: _______________________________________________________ Date: _________________________

This form must be completed, printed, and mailed, emailed (scanned as a PDF file), or faxed to the Director of the Program.

Page 10

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