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Elements Application1 (West Georgia College)

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Elements 2017 Program Application
Elements, New Student Outdoor Program, is an outdoor adventure experience for new incoming freshmen to the University of West
Georgia. Students will embark on a 5-day/4-night adventure before the start of the fall semester in some of the Southeast’s most
scenic outdoor destinations. Activities could include backpacking, canoeing, rafting, climbing, and zip lining. Each trip will have
several fun and exciting components throughout to keep the groups engaged and challenged. Groups will consist of nine student
participants and two outdoor program instructors in order to create a family like atmosphere. By the end of the week, participants and
leaders will have the opportunity to get to know other incoming freshmen, form new friendships, create lasting memories, and
discover new outdoor experiences before their West Georgia journey begins.
Program Dates
July 31 - August 5, 2017
Schedule
July 31 – Early Move-In and Welcome Banquet
August 1 – Trips Leave UWG Day 1 / Night 1
August 2-4 – Trips are Backpacking, Climbing, Paddling, Camping, Etc.
August 5 – Trips Return to UWG and will be back by Noon
Registration Instructions
Please complete the following to register for Elements 2017:
1. Program Application – The program application includes a medical form, program liability waiver, safety expectations, and
questionnaire to help UWG assess what concerns students may have prior to the start of the school year.
**All applications will be reviewed after registration has closed. This is NOT a first come/first serve registration process. Participants NOT selected to
participate will be notified and a refund will be administered.**
2. Proof of
Insurance – All Element participants must provide proof of health insurance before acceptance into the program.
Due to the nature of outdoor activities and travel logistics, UWG is requiring every participant to carry health insurance for the
duration of the program. Please send a copy of the front and back of your insurance card (please note: this should be for the
participant, not the policy carrier). Please attach all copies to the program application.
3. Program Payment – Program fees may be paid by credit card / debit card on the University Recreation’s program portal
(MyRec). Please visit the Elements’ website for more information and instructions. (www.westga.edu/UREC). Program
registration is $150.00 per participant and includes Equipment, Transportation, Food, Permits, Instructors, and Outfitter Fees.
Fee does not include personal items, clothing, rain jacket/pants, proper hiking shoes, and food kit. A detailed packing list
will be supplied by Elements June/July. In the event that a participant can no longer attend Elements, a full refund may be
issued up until the end of the application period.
4. Form Submission – Please send your Program Application and Proof of Insurance by email, fax, or mail.
Email signed documents to wgo@westga.edu
-or-
Mail signed documents to:
University of West Georgia
c/o Mark Henley, University Recreation
1601 Maple St
Carrollton, GA 30118
-or
Fax signed documents to 678-839-0661 Attn: Mark Henley
For acceptance to Elements 2017, all registration material and payment must be received no later than
Friday June 16th, 2017 - 5:00 PM
Elements Registration / Medical Form
please note: Incoming freshman who wish to participate in Elements must be accepted and attending the University of West Georgia
in the fall 2017 semester. Please completely fill out the following registration/medical form with current and accurate information.
Name _______________________________________________________________________________
Address _____________________________________________________________________________
City/State/Zip ________________________________________________________________________
Email Address ______________________________________ Date of Birth _______/_______/_______
D
ay Phone (_____) __________________________________ Evening Phone (____) ___________________________________
Gender: Male _______ / Female ______
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Fa
ther/Guardian ___________________________________ Mother/Guardian _____________________________________
City/State/Zip ______________________________________ City/State/Zip _________________________________________
Occupation/Title ____________________________________ Occupation/Title _______________________________________
Day Phone (_____) __________________________________ Day Phone (_____) _____________________________________
Evening Phone (____) ________________________________ Evening Phone (____) ___________________________________
Cell Phone (____) ___________________________________ Cell Phone (____) ______________________________________
Email Address ______________________________________ Email Address _________________________________________
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Emergency Contact
Name _____________________________________________
Relationship ________________________________________
Day Phone (_____) __________________________________
Evening Phone (____) ________________________________
Cell Phone (____) ___________________________________
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Insurance Information
Element participants must provide proof of health insurance.
Insurance Company Name ________________________________ _______ Policy Number ______________________________________
Claim Billing Address __________________________________________ City/State/Zip _______________________________________
Prescription Plan Name _________________________________________ Policy Number ______________________________________
Claim Billing Address __________________________________________ City/State/Zip _______________________________________
NOTE: ATTACH A PHOTOCOPY OF BOTH THE FRONT AND BACK OF YOUR INSURANCE CARD(S) TO THIS FORM.
SIGNATURE(S) REQUIRED
By signing below, I hereby acknowledge that all of the above information is true to the best of my knowledge. Furthermore, I acknowledge
that by providing false information, I may hinder any attempts by University Recreation or other medical personnel to give care to me in the
event of an emergency.
Student’s Signature Date
Parent/Guardian Signature (if participant under 18) Date
PAST AND PRESENT MEDICAL PROBLEMS
CONDITIONS AND SYMPTOMS
Yes No Yes No Yes No
1.High Blood Pressu
re □ □ 24.Headaches □ □ 46.Special Diet □ □
2.Heart Disease □ □ 25.Head injury w/ □ □ 47.Learning Disability □ □
3.Heart Murmur □ □ neurological impairments □ □ 48.Unexplained Weight Loss □ □
4.Irregular Heartbeat □ □ 26.Stomach Ulcers □ □ Do you currently or regularly have
5.Family history of heart attack □ □ 27.Intestianl Issues □ □ any of the following symptoms?
6.Tuberculosis □ □ neurological impairments 49.Chest Pain/Pressure □ □
7.Recent exposure to active TB □ □ 28.Heatstroke □ □ 50.Heart Palpitations □ □
8.Positive TB test □ □ 29.Bladder Infection □ □ 58.Shortness of Breath □ □
9.Active Hepatitis □ □ 30.Difficulty Urinating □ □ 60.Frequent Dizziness □ □
10.History of Hepatitis □ □ 31.Kidney Issues □ □ 61.Frequent Fainting □ □
11.Seizure Disorder □ □ 32.Thyroid Issues □ □ 62.Heartburn □ □
12.Seizure within past year □ □ 33.Hearing Impairment □ □ 63.Muscle Cramps □ □
13.Bleeding Disorder □ □ 34.Vision Impairment □ □ 64.Intolerance to warm temps □ □
14.Blood disorder/anemia/ □ □ 35.Motion Sickness □ □ 65.Intolerance to cold temps □ □
Sickle cell trait 36.Cronic Sleep Walking □ □ 66.PMS or menstrual issues □ □
15.Chronic cough □ □ 37.Broken Bones □ □
16.Recurrent lung infections □ □ 38.Neck Issue □ □
17.Asthma □ □ 39.Back Issues □ □
18.Diabetes □ □ 40.Arm Issues □ □
19.Hypoglycemia □ □ 41.Shoulder Issues □ □
20.Cancer □ □ 42.Knee Issues □ □
21.Skin Issues □ □ 43.Ankle Issues □ □
22.Frostbite □ □
44.Leg Issues □ □
2
3.Cirrculation Issues □ □ 45.Foot Issues □ □
IF YOU HAVE ANSWERED “YES” TO ANY OF THE ABOVE ITEMS, PLEASE EXPLAIN BELOW. INCLUDE THE FOLLOWING:
-What s
pecific symptoms are occurring -How long symptom/condition lasts
-How often symptom/condition occurs -How you care for symptom/condition
-Date of last occurrence
-How symptom/condition restricts your activity in any way, including your ability to run, lift, paddle, swim, and climb
Item #
Detailed Description (Including Restrictions if any)
ALLERGIES / FOOD RESTRICTIONS
Do you have any food restrictions? (i.e. Vegetarian, Gluten Free, etc.) Yes _______ / No _______
If yes, please define restrictions __________________________________________________________________________________________
Are you allergic to any types of food? Yes _______ / No _______
If yes, please define allergies ____________________________________________________________________________________________
OTHER ALLERGIES
INCLUDING ALLERGIES TO MEDICINES, INSECT BITES/STINGS, ENVIRONMENTAL
NONE OR
Allergy
Reaction
Medication Required
MEDI
CATIONS YOU ARE CURRENTLY TAKING
LIST ANY MEDICATIONS YOU ARE PRESCRIBED, INCLUDING PSYCHIATRIC AND OVER THE COUNTER MEDICATIONS
NONE OR
Medication
Dosage
Date Started
Side Effect
NOT
E: If you are taking medication(s), please bring double amounts in original container(s), with prescription label intact
ALL MEDICATION LISTED MUST ACCOMPANY STUDENT ON COURSE!
TRIP EXPECTATIONS / SAFETY REQUIREMENTS
Please review and acknowledge these personal safety requirements needed to participate in Elements 2017. Refer to trip itineraries for
information related to the following.
• Participant must possess the ability to walk, stand, and lift ~40 lbs over uneven surfaces for up to 8 hours per day
• Some t
rip components require participants to paddle for extended periods of time
• Some trip components involve open water where participants must possess the ability to swim*
• For trip selection accuracy, please indicate your swimming ability
o Yes_____ / No _______
• No tobacco, alcohol, illegal drugs, or weapons allowed
*Some
trip itineraries will not contain water activities, thus swimming ability is not a requirement to participate in Elements 2017.
I, ______________________________, understand the personal safety requirement aforementioned.
PROGRAM SHIRT
(Adult Sizes Only)
Large
University of West Georgia (UWG)
Release, Waiver of Liability, and Covenant Not to Sue
Activity: Elements, Pre-Semester Program for Incoming Freshman (Canoeing & Backpacking)
Date/Time: 8/1/2017-8/5/2017
Location: Lake Jocassee/Foothills Trail, SC/NC
Location: Chattooga River Trail, GA,SC,NC
Acknowledgment and Assumption of Risk:
I wish to participate in the activity specified above. I am aware that this activity may be a vigorous activity that I can involve inherent
risks of physical injury, illness or loss of personal property and I assume all such risks. I also understand that there are potential risks
of which I may not presently be aware including, but not limited to, travel to and from the site of activity, participation at sites that
may be remote from available medical assistance, and exposure to the possible reckless conduct of other participants.
Nevertheless, I voluntarily elect to participate in this activity with knowledge of the danger involved, and I hereby agree to
accept and assume any and all risks of property damage, personal injury, or death.
Waiver of Liability and Indemnification:
In consideration for being allowed to voluntarily participate in the above-referenced activity, on behalf of myself, my personal
representatives, heirs, next of kin, successors and assigns, I forever:
a. Waive, release, and discharge the University of West Georgia and the Board of Regents of the University System of
Georgia, its members individually, its agencies, officers, and employees from any and all negligence and liability for my
death, disability, personal injury, property damages, property theft or claims of any nature which may hereafter accrue to
me, and my estate as a direct or indirect result of my participation in the above referenced activity or event.
b. Indemnify, save, and hold harmless the University of West Georgia and the Board of Regents of the University
System of Georgia, its members individually, its agencies, officers, and employees of, from and against any and all
claims of any nature including all costs, expenses, and fees arising out of or resulting from my actions during this
activity or event.
c. I, the undersigned participant, affirm that I am at least 18 years of age and am freely signing this agreement. I have read
this form and fully understand that by signing this form I am giving up legal rights and/or remedies which may
otherwise be available to me regarding any losses I may sustain as a result of my participation. I agree that if any portion
is held invalid, the remainder will continue in full legal force and effect.
Participant Name: ________________________________________ Age: _____________
Participant Signature: _____________________________________ Date: _____________
Parent/Guardian Signature (if participant is under 18): ________________________________________
Questionnaire
How did you hear about Elements?
____ Email ____ Websi
te – Admissions Page
____ Preview Day ____ Website – University Recreation Page
____ Word of Mouth ____ Other
Pick your top three reasons for registering for Elements.
____ Experience outdoor recreation activities ____ Learn more about UWG
____ Make friends before the semester starts ____ Prepare for life in college
____ Try something new ____ Move-in early to my Residence Hall
____ Gain leadership skills ____ This will make me more successful at UWG
Please rank the following statements; 1 is low and 5 is high.
What is your general anxiety level about the transition from high school to college?
What is your level of anxiety about being away from your family as you start college?
How worried are you about finding friends at the University of West Georgia?
How worried are you about overcoming issues in diversity in college?
How confident are you about starting college?
How comfortable are you with your overall wellness going in to college?
Why do you want to participate in Elements?
What is your previous experience with outdoor recreation activities?
**No prior experience is required to participate**
What do you hope to get out of participating in this trip?
1
1
1
1
1
1
Sample Trip Itinerary
All trips are subject to change due to weather, land permits, group ability, equipment, and safety measures. Final trip itineraries will
be communicated out prior to the trip in July 2017.
July 31, 2017
Element Participants arrive to UWG to move-in early and attend the pre-trip program banquet
August 1, 2017 (Day1)
Groups will depart UWG at 9:00 AM and travel to Devil’s Fork State Park, SC
Campsites will be set up and established
Canoe and water safety / techniques will be taught in the afternoon
Paddle to Wrights Creek Falls and back to campground (6 miles)
Dinner and day 1 debrief will be held around the campfire
August 2, 2017 (Day2)
Groups will pack up and store equipment in provided dry bags
Paddle to Laurel Creek Falls for lunch and exploration (5 miles)
Paddle to Toxaway Creek Campsite on Foothills Trail (3 miles)
Meet up with another Element’s group
Dinner and day 2 debrief
August 3, 2017 (Day 3)
Exchange equipment with other group (canoe/dry bags with backpacks)
Start backpacking on Foothills Trail (10 miles)
Setup camp along Laurel Creek
Dinner and day 3 debrief
August 4, 2017 (Day 4)
Early morning wake up
Finish backpacking to Van
Load up and head to Outfitter for a day of rafting and waterfall rappelling
Finish with Outfitter and head to celebratory dinner
Drive to Lake Hartwell State Park, SC
Day 4 debrief
August 5, 2017 (Day 5)
Groups will return to UWG by Noon
Gear return and debrief
Program T-Shirt and closing remarks
UWG Move-In Day / Pack Premiere
Element participants start their UWG journey
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Elements Application1 (West Georgia College)

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