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
***P A R E N T A L / G U A R D I A N N O T I F I C A T I O N***
V I O L A T I O N S A N D P E N A L T I E S
