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FAMILY CAMP SUMMER (School of the Art Institute of Chicago)

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FAMILY CAMP
SUMMER
Attached you will find four documents:
• Family Camp Registration Form
• Consent Form
• Allergy History Form
All students must complete and return the Family Camp Registration Form and Consent
Form. Students with allergies or other medical/health conditions that may require emergency
assistance should also complete the Allergy History form and/or Emergency Action Plan
included in this document.
Note: To ensure that you receive all future communication, including registration confirmation,
welcome message, notices regarding road closures, etc., please include a valid email address
in the STUDENT INFORMATION and/or PARENT INFORMATION section of the registration form
and add cs@saic.edu to your contacts.
Parents are encouraged to complete and return all forms at the time of registration to expedite
check-in on the first day of class. Failure to do so may result in longer wait times.
Additional details regarding the program can be found online at Children’s Programs>Summer
Camps>Student Information.
ARTICard (Student ID)
Send in a photo of your student for use on their ARTICard! The ARTICard is the student ID card
at SAIC, which students use to enter campus buildings. Visit http://tinyurl.com/csprograms-
articard for details about photo specifications and the required Terms and Conditions form.
Date of Birth (MM/DD/YYYY)
Family Camp Registration Form
ADULT STUDENT INFORMATION (PLEASE COMPLETE ALL FIELDS AND PRINT CLEARLY)
CHILD STUDENT #2 INFORMATION
EMERGENCY CONTACT INFORMATION
CHILD STUDENT #1 INFORMATION
Address
Address
Address
Apartment
Apartment
Apartment
City
City
City
STUDENT GENDER:
STUDENT GENDER:
STUDENT GENDER:
Date of Birth (MM/DD/YYYY)
Date of Birth (MM/DD/YYYY)
State
State
State
Year: 20
Zip Code
Zip Code
Zip Code
Primary Email Address (confirmation will be sent here)
Primary Email Address (confirmation will be sent here)
Primary Email Address (confirmation will be sent here)
Email Address
Legal Last Name
Legal Last Name
Last Name
Legal Last Name
Legal First Name
Legal First Name
First Name
Legal First Name
Preferred Name
Preferred Name
Preferred Name
MI
MI
MI
ID # (if returning)
ID # (if returning)
ID # (if returning)
Female
Female
Female
Male
Male
Male
Summer
Signature required of student or parent/legal guardian if student is under 18 years of age.
Date
X
COURSE SELECTIONS
Class number Class dates Day(s) Meeting timesTitle
School Name/Type:
School Name/Type:
Grade
Grade
HS Grad Year
HS Grad Year
Relationship to Child Student #1 Relationship to Adult Student Relationship to Child Student #2
Public
Public
Home School
Home School
Parochial
Parochial
Private/Independent
Private/Independent
Charter/Magnet
Charter/Magnet
Note: If your student has a medical/health condition or disability that may require emergency/classroom assistance, please complete the Allergy History Form and/or Emergency Action Plan form available
in the Forms and Downloads section of the website, or email cs@saic.edu with details.
CONTINUING STUDIES ACKNOWLEDGMENT + AGREEMENT
Registration/Cancellation: I understand that I am financially responsible for the course(s) for which I am registering. A full refund will be granted for cancellations submitted in writing or in person before the start of the second class. I agree
to the foregoing on behalf of myself/my child or ward.
Primary Phone:
Primary Phone:
Primary Phone:
Phone Number:
Secondary Phone:
Secondary Phone:
Secondary Phone:
Secondary Phone:
Mobile
Mobile
Mobile
Mobile
Mobile
Mobile
Mobile
Mobile
Home
Home
Home
Home
Home
Home
Home
Home
Work
Work
Work
Work
Work
Work
Work
Work
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DISCOUNT INFORMATION
PAYMENT INFORMATION
CREDIT CARD INFORMATION
CREDIT CARD INFORMATION
BILLING ADDRESS:
CARD TYPE:
TOTAL AMOUNT DUE:
Discounts must be calculated and reflected in payment at the time of registration; discounts will not be applied retroactively and refunds will not be issued to correct
overpayment. Only one tuition discount may be applied to a student’s account per semester.
Art Institute of Chicago (AIC) Members: School of the Art Institute of Chicago (SAIC) Alumni:
Membership Number
SUMMER TUITION: ONE-WEEK SESSION HALF DAY
Alumni ID Card Number
Note: To receive an alumni discount, you must have completed a degree / certificate program here at SAIC. Note: If a recent member, please indicate the confirmation / transaction ID number.
Membership Expiration Date Year of Graduation / Certificate Completion
TOTAL # OF STUDENTS x TUITION = TOTAL AMOUNT DUE
American Express Discover
Check - payable to SAIC
Visa
Money Order - payable to SAIC
MasterCard
Tuition: $232.50
Credit Card
AIC Member Tuition: $209 SAIC Alumni Tuition: $174.50
Cardholder’s Name (as it appears on the card)
Address
Credit Card Number Expiration Date Security Code
Phone Number Email Address (Note: card receipt will be sent here)
StateCity Zip Code
Apartment
Term
Adult Student Name ID # (if returning) Tuition
ID # (if returning) Tuition
ID # (if returning) Tuition
Child Student #1 Name
Child Student #2 Name
All students will receive an ARTICard, SAIC’s mandatory identification card. This card permits access to School facilities and the Art Institute of Chicago museum, and
must be worn at all times. Students who send in the required items will receive their ID on the first day of class. Students who are unable to attend the first day should
still send in their photo for an ID. Please visit tinyurl.com/CS-articard for details, and tinyurl.com/articardFAQ for info.
ARTICARD (STUDENT ID)
Student Name:
ID Number:
Class Number(s):
CONSENT FORM
This form is required for participation in Children’s Workshops in Art + Creativity, the Middle School Program, and the
Early College Program, and is valid and for one term. Forms must be signed, as typed names cannot be accepted.
ACKNOWLEDGMENT and AGREEMENT
Medical: I give SAIC permission to obtain emergency medical care, hospital, or clinic treatment for me. I hereby waive
liability against SAIC for such care and for transportation provided to such locations as deemed necessary by SAIC.
Rules of Conduct: I have read and agree to abide by the SAIC Rules of Conduct listed online in Forms and Downloads. If
in ECP, I have read and agree to abide by the SAIC Student Rights and Responsibilities listed online.
Photo/Video: I give SAIC permission to video or photograph me participating in instructional and/or social activities at
SAIC and to publish such videos or photographs. I agree to the forgoing on behalf of myself/my child or ward.
Participation in Field Trips
In consideration of my minor child or ward (“Student”) being allowed to participate in any field trip conducted as part
of SAIC’s Youth Programs, I do hereby, for myself, the Student and my dependents, heirs, executors, administrators,
agents and assigns, agree to waive, hold harmless, indemnify, covenant not to sue, release, and forever discharge the Art
Institute of Chicago, the School of the Art Institute of Chicago and their trustees, ocers, employees, members, agents,
successors, and assigns (hereafter collectively referred to as “Releasees”), for and from any and all responsibility, liability,
causes of action suites, damages, demands, and claims whatsoever which I, the Student or those claiming under either of
us may have, suer, or incur now or in the future resulting from or arising out of the Student’s participation in said field
trip and any direct or indirect event in connection therewith occurring before, during and/or after said trip, including,
but not limited to claims for death, personal injury, property damage or loss, whether arising out alleged strict liability,
negligence of Releasees, or otherwise.
On behalf of myself and the Student, I further agree to indemnify and hold harmless said Releasees of and from all
liabilities described above, arising out of or connected with the Student’s participation in said field trip, including any
claims of third persons relating to the above matters, whether by subrogation or otherwise.
Parent/guardian signature: Date:
MIDDLE SCHOOL PROGRAM (AGES 10-13) ONLY:
Permission for Unescorted Dismissal
Students are not permitted to leave campus unescorted without prior written approval indicated on the Consent Form
(last section). If you prefer to allow your child to leave at the end of class without the presence of an approved parent
or guardian holding a pick up pass, complete this part of the consent form by checking “yes” and signing. (Not valid for
students in Children’s Workshops in Art and Creativity or the Early College Program).
My child/ward may leave unescorted at time of class dismissal. YES NO
Parent/guardian signature: Date:
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Complete this form only if your child has an allergy that may require emergency assistance. If emergency medication may be required
while your child is at SAIC, an Emergency Action Plan (EAP) form must be completed by your child’s physician and submitted prior to
the start of class. SAIC sta members are not able to administer emergency medication without a completed Emergency Action Plan
on file from your child’s physician.
STUDENT NAME (PLEASE PRINT): ID NUMBER:
ALLERGENS:
WHEN AND HOW DID YOU FIRST BECOME AWARE OF THE ALLERGY?
WHEN WAS THE LAST TIME YOUR CHILD HAD A REACTION?
PLEASE DESCRIBE THE SIGNS AND SYMPTOMS OF THE REACTION:
WHAT MEDICAL TREATMENT WAS PROVIDED, AND BY WHOM?
SAIC sta members are not trained medical professionals. However, they have been trained to administer EpiPens in the event of an
emergency. For students enrolled in the Children’s Workshops, parents are required to provide SAIC with an EpiPen to be stored on-
campus for the duration of their child’s class. The EpiPen must be clearly marked with the child’s name. For Middle School and Early
College Program students, SAIC expects that the students will carry their own medication.
SAIC sta members will only administer medication in the event of an emergency. All other non-emergency medication should be self-
administered or be arranged to be administered by parents.
Please note that SAIC sta are not able to administer over-the-counter (non-prescription) medication, even if a physician indicates
use of said medication in the student’s Emergency Action Plan (EAP). If non-prescription medication is indicated on a student’s EAP,
parents will be asked to follow up with their physician to update the form.
PARENT/GUARDIAN NAME (PLEASE PRINT): PARENT/GUARDIAN SIGNATURE: DATE:
ALLERGY HISTORY & INFORMATION FORM
Phone:
Phone:
Phone:
Name/Relationship:
I hereby authorize the school district staff members to take whatever action in their judgment may be necessary in supplying emergency medical
services consistent with this plan, including the administration of medication to my child. I understand that the Local Governmental and Govern-
mental Employees Tort Immunity Act protects staff members from liability arising from actions consistent with this plan. I also hereby authorize
the school district staff members to disclose my child’s protected health information to chaperones and other non-employee volunteers at the
school or at school events and field trips to the extent necessary for the protection, prevention of an allergic reaction, or emergency treatment of
my child and for the implementation of this plan.
Name/Relationship:
Parent/Grardian Signature:
LICENSED HEALTHCARE
PROVIDER SIGNATURE: Phone:
(REQUIRED)
Date:
Date:
ILLINOIS FOOD ALLERGY EMERGENCY ACTION PLAN
AND TREATMENT AUTHORIZATION
ANY SEVERE SYMPTOMS AFTER SUSPECTED
INGESTION:
LUNG: Short of breath, wheeze, repetitive cough
HEART: Pale, blue, faint, weak pulse, dizzy, confused
THROAT: Tight, hoarse, trouble breathing/swallowing
MOUTH: Obstructive swelling (tongue)
Or COMBINATION of symptoms from dierent body areas:
SKIN: Hives, itchy rashes, swelling
GUT: Vomiting, crampy pain
EPINEPHRINE (BRAND AND DOSE):
ANTIHISTAMINE (BRAND AND DOSE):
OTHER (E.G., INHALER-BRONCHODILATOR IF ASTHMA):
CONTACTS: Call 911 Rescue Squad:
Parent/Guardian:
MILD SYMPTOMS ONLY:
MOUTH: Itchy mouth
SKIN: A few hives around mouth/face, mild itch
GUT: Vomiting, crampy pain
If checked, give epinephrine for ANY symptoms if the allergen was likely eaten.
If checked, give epinephrine before symptoms if the allergen was definitely eaten.
INJECT EPINEPHRINE IMMEDIATELY
• Call 911
• Begin monitoring (see below)
• Antihistamine
• Inhaler (bronchodilator) if asthma
*Inhalers/bronchodilators and antihistamines are not
to be depended upon to treat a severe reaction
(anaphylaxis) use Epinephrine*
**When in doubt, use epinephrine. Symptoms can
rapidly become more severe.**
GIVE ANTIHISTAMINE
• Stay with child, alert health care professionals and parent.
IF SYMPTOMS PROGRESS (see above), INJECT EPINEPHRINE
D.O.B:
GRADE:
NAME:
TEACHER:
CHILD’S
PHOTOGRAPH
ALLERGY TO:
ASTHMA: YES (HIGHER RISK FOR A SEVERE REACTION)
Student may self-carry epinephrine Student may self-administer epinephrine
NO WEIGHT: lbs
MONITORING: Stay with the child. Tell rescue squad epinephrine was given. A second dose of epinephrine can be
given a few minutes or more after the first if symptoms persist or recur. For a severe reaction, consider keeping
child lying on back with legs raised. Treat child even if parents cannot be reached.
MEDICATIONS/DOSES
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Room:
Room:
Room:
Name:
Name:
Name:
This document is based on input from medical professionals including Physicians, APNs, RNs and certified school
nurses. It is meant to be useful for anyone with any level of training in dealing with a food allergy reaction.
• Gather accurate information about the reaction, including who assisted in the medical intervention and who witnessed the event.
• Save food eaten before the reaction, place in a plastic zipper bag (e.g., Ziploc bag) and freeze for analysis.
• If food was provided by school cafeteria, review food labels with head cook.
• Follow–up:
• Review facts about the reaction with the student and parents and provide the facts to those who witnessed the reaction or are involved
with the student, on a need-to-know basis. Explanations will be age-appropriate.
• Amend the Emergency Action Plan (EAP), Individual Health Care Plan (IHCP) and/or 504 Plan as needed.
• Specify any changes to prevent another reaction.
Ann & Robert H. Lurie Children’s Hospital of Chicago
800-KIDS-DOC
https://www.luriechildrens.org
Food Allergy Research and Education
800-929-4040
http://www.foodallergy.org
DOCUMENTATION
LOCATION OF MEDICATION
ADDITIONAL RESOURCES
TRAINED STAFF MEMBERS
STUDENT TO CARRY
HEALTH OFFICE/ DESIGNATED AREA FOR MEDICATION
OTHER:
DEARBORN
JACKSON
VAN BUREN
ADAMS
MONROE
MADISON
WASHINGTON
RANDOLPH
CONGRESS
WABASH
STAT E
MICHIGAN
COLUMBUS
LAKE SHORE DRIVE
LAKE
HARRISON
BALBO
8
4
5
7
6
1
2
3
9
10
11
12
13
14
Lake Michigan
Chicago River
Millennium
Park
Grant
Park
1. 280 South Columbus Drive
280 S. Columbus Dr.
2. The Art Institute of Chicago
111 S. Michigan Ave.
3. The Modern Wing
159 E. Monroe St.
4. 116 South Michigan Avenue
116 S. Michigan Ave.
5. MacLean Center
112 S. Michigan Ave.
6. Sharp Building
37 S. Wabash Ave.
7. The LeRoy Neiman Center
37 S. Wabash Ave.
8. Sullivan Center
36 S. Wabash Ave.
9. Sullivan Galleries
33 S. State St.
10. Jones Hall
7 W. Madison Ave.
11. 162 North State Street Residences
162 N. State St.
12. Gene Siskel Film Center
164 N. State St.
13. The Buckingham
59 E. Van Buren St.
14. Spertus Building
610 S. Michigan Ave.
Campus Map
N
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Completed 26 August 2020

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