Student Name:_________________________________________________________________
Home Address:_________________________________________________________________
City:______________ State:_____________ Zip:________________ Phone:________________
Email (for confirmation/acceptance letters):__________________________________________
Date of Birth:_____________________
Ethnicity: African American Asian Caucasian/White
Hispanic/Latino Native American Other:
Name of school presently attending:________________________________________________
Current grade in school: 9
th
10
th
11
th
12
th
Have you previously attended a Scrubs Camp? Yes No
Name of Parent/Guardian:________________________________________________________
Home Address:_________________________________________________________________
City:______________ State: ________________ Zip:___________________________________
Daytime Phone Number:___________________ Evening Phone Number: __________________
Email:_________________________________________________________________________
Are you interested in a healthcare career?
Yes No Unsure
If you answered “yes” above, what healthcare career(s) are you interested in pursuing?
______________________________________________________________________________
P E R S O N A L I N F O R M A T I O N
P A R E N T A L / G U A R D I A N I N F O R M A T I O N
C A R E E R I N T E R E S T
Signature:_______________________________________ Position:_______________________
Print Name:______________________________________Phone:________________________
Email:_________________________________________________________________________
Will you be attending with your student? Yes No
Will you be attending lunch? Yes No
The Scrubs Camp is designed to be an educational function, and all plans are made with that
objective. Many local school districts approve it as an educational activity, and hundreds of
students attend the Camps from all over the state.
Scrubs Camp management wants every attendee to have an enjoyable experience with every
attention paid to education, safety and comfort. All attendees will be expected to conduct
themselves in a manner best representing their local school district. In order that everyone may
receive the maximum benefits from participation, the “Code of Conduct” must be followed at
all times.
Note that attendance is not mandatory. By voluntarily participating, you agree to follow the
official Scrubs Camp rules and regulations or forfeit your personal rights to participate. Each
local school district is proud of its students and knows that by signing this “Code of Conduct”
you are simply reaffirming your dedication to be the best possible representative of your
school.
1. I will, at all times, respect all public and private property, including the facility where I
attend the Scrubs Camp.
2. I will, at all times, respect all individuals (other students and adults) while in attendance
at the Scrubs Camp. I will not use profanity of any kind while in attendance at the Scrubs
Camp.
3. I will not use alcoholic beverages, tobacco products, or illicit drugs of any kind while in
attendance at the Scrubs Camp. I will not
use drugs unless I have been ordered to take
certain
prescription medications by a licensed
physician. If I am required to take
medication, I will, at all times, have the orders of the physician on me.
4. I will not leave the Scrubs Camp without the express permission of my advisor, Scrubs
Camp Site Coordinator, or Scrubs Camp Project Coordinator. Should I receive
permission, I will leave a written notice of where I will be with my advisor, Scrubs Camp
Site Coordinator, or Scrubs Camp Project Coordinator.
5. My conduct shall be exemplary at all times while at the Scrubs Camp.
6. I will keep my advisor, the Scrubs Camp Site Coordinator, or the Scrubs Camp Project
Coordinator informed of my whereabouts at all times.
7. I will wear my Scrubs Camp identification badge at all times while at the Scrubs Camp.
8. I will attend and be on time for all Scrubs Camp sessions and activities.
S C H O O L C O U N S E L O R , T E A C H E R , O R A D M I N I S T R A T O R
C O D E O F C O N D U C T A G R E E M E N T
click to sign
signature
click to edit
Your signature below authorizes the South Dakota Department of Education (SD DOE) and the
South Dakota Department of Health (SD DOH) to release all information contained in this
registration application to the South Dakota Area Health Education Center (AHEC). This
information will be maintained and referenced periodically to evaluate the effectiveness of the
Scrubs Camps. Students participating in the Scrubs Camps may be contacted in the future for
evaluation purposes.
In consideration of the student’s acceptance into and participation in the Scrubs Camp, any and
all claims that the student and/or the student’s parents, guardians, heirs, agents,
representatives, successors or assigns might have against the South Dakota Department of
Education and/or South Dakota Department of Health, its employees, contractors, grantees,
sponsors, officials and volunteers, for any and all injury or illness which may directly or
indirectly result from the student’s participation in this program are waived by signing below.
By signing below, the facilitators of the Scrubs Camps are granted the non-exclusive and
irrevocable rights and license to make, edit, and use pictures for publicity, news or advertising;
including print, video, broadcast media and the internet. The facilitators of the Scrubs Camps
are released from any and all claims of payment for performance rights, residuals or damages
for libel, slander, invasion of privacy, or any claim based on the use of said material.
Due to the nature of this camp, students may be exposed to latex, finger stick blood sampling,
and other elements of a basic physical exam. By signing below, the student’s parent/guardian
acknowledges and accepts these possible risks.
I agree that if, for any reason, I am in violation of any of the rules of the Scrubs Camp, I may be
sent home at my own expense. I understand that notification of the violation and the action
taken will be sent to my local school district and parents or guardians. I understand that
through my negative actions, Scrubs Camp attendees from my local school district could be sent
home as well.
It is within the spirit of being a proud and meaningful attendee of the Scrubs Camp that I agree
to these rules of conduct by signing my name on this registration form. By signing this
registration form, my parent and/or guardian, as well as a school district representative, affirm
that I am worthy to attend a Scrubs Camp
Parent/Guardian Signature:__________________________________ Date:________________
Print:_________________________________________________________________________
Student Signature:_________________________________________ Date:_________________
Print:_________________________________________________________________________
*If you have a food allergy, please provide your own lunch.
L I A B I L I T Y & P H O T O W A I V E R
V I O L A T I O N S A N D P E N A L T I E S
S I G N A T U R E S
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