CAREER EXPLORATION SUMMER CAMP 2014 A Summer Camp experience presented by Caroline, and Stafford County Public Schools, and Germanna Community College

APPLICATION Please complete and return to your child’s guidance counselor The Career Exploration Summer Camp is funded through a grant from Germanna Community College. Its purpose is to give rising eighth grade students an opportunity to learn about their interests and abilities and how these relate to a career. Students will also have the opportunity to learn about the variety of career opportunities available and the importance of early career planning. Participation will be limited to a first-come first-served basis. The Camp will be planned, staffed and supervised by faculty from the participating school districts and Germanna Community College. Detailed information is listed on the attached information sheet. Transportation will be provided by certain school districts and a schedule will be announced before Camp begins. Please speak with your guidance counselor to see if your school provides transportation. Students will be provided a lunch and snack each day. A picnic is planned for the final day of camp, and parents are encouraged to attend. Students are expected to attend the entire five-day Camp. Applicant Information (please type or print clearly):

Last Name

First Name

Middle

Address

City

Today’s Date

Phone

State

Zip

School Name

Birth Date:__________________

Emergency Contact Information (required): Mother’s (or Guardian’s) Name:________________________________

Daytime Phone:______________________

Father’s Name:________________________________

Daytime Phone:______________________

Emergency Contact Person:_______________________

Phone:_____________________________

MEDICAL INFORMATION We take health and safety seriously. The medical information provided in this form is important for the safety and welfare of your child. We will keep the information on file during the camp program. It will be invaluable to us in case of an emergency. This form must be completed and on file before your child is officially accepted. Please supply us with the following important information: Student Information: Last Name:

First: __________________________

Home Address:

City: ___________________________

State:

Zip:

Home Phone:

Birthday:________________________

Father’s Information:

Mother’s Information:

Employer:

Employer:______________________

Phone: ______________________________

Phone: ___________________________

E-mail address: ___________________________

E-mail address:_____________________

Person to contact in case of emergency if parents are unable to be reached: Name:

Relationship:

Phone: Medical Insurance Information (required): Please list the name of your medical insurance company:__________________________________ Member’s Name: Membership Number: ______________ Group Number: Family Doctor:___________________ Phone: General Medical Information (required): Does your child have any of the following medical conditions? Please check all that apply: ____Diabetes ____Heart Problems ____Epilepsy ____Hypertension ____Motion Sickness when traveling ____Allergic to Bee stings ____Other allergies If other please list: Does your child take medication on a continuous basis? Please list:

Does your child suffer allergic reactions to any foods or medications? Please list:

The Germanna Community College Staff and/or Summer Camp Counselors have my permission to seek emergency medical services for my child. ____________________________________ Parent or Guardian’s signature

___________________________ Date

ASSUMPTION OF THE RISK FORM I agree that as a participant in the Career Exploration Summer Camp 2014 at Germanna Community College associated with Germanna Community College (the “College”) scheduled for July 7th-July 11th, I am responsible for my own behavior and well-being. I accept this condition of participation, and I acknowledge that I have been informed of the general nature of the risks involved in this activity, including, but not limited to: Travel to and from the activity and participation in the selected activities I understand that in the event of accident or injury, personal judgment may be required by Gold’s Gym, Mary Washington Healthcare, or College personnel regarding what actions should be taken on my behalf. Nevertheless, I acknowledge that the College, Gold’s Gym and/or Mary Washington Healthcare personnel may not legally owe me a duty to take any action on my behalf. I also understand that it is my responsibility to secure personal health insurance in advance, if desired, and to take into account my personal health and physical condition. I further agree to abide by any and all specific requests by the College, Gold’s Gym and/or Mary Washington Healthcare for my safety or the safety of others, as well as any and all of the College’s, Gold’s Gym and/or Mary Washington Healthcare rules and policies applicable to all activities related to this program. I understand that the College reserves the right to exclude my participation in this program if my participation or behavior is deemed detrimental to the safety or welfare of others. In consideration for being permitted to participate in this program, and because I have agreed to assume the risks involved, I hereby agree that I am responsible for any resulting personal injury, damage to or loss of my property which may occur as a result of my participation or arising out of my participation in this program, unless any such personal injury, damage to or loss of my property is directly due to the negligence of the College, Gold’s Gym and/ or Mary Washington Healthcare. I understand that this Assumption of Risk form will remain in effect during any of my subsequent visits and program-related activities; unless a specific revocation of this document is filed in writing with Canice Graziano, Coordinator of Dual Enrollment, at which time my visits to or participation in the program will cease. In case an emergency situation arises, please contact (NAME): (PHONE #):

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I acknowledge that I have read and fully understand this document. I further acknowledge that I am accepting these personal risks and conditions of my own free will. My child/ward is under 18 years of age and I hereby provide permission for him/her to participate in this program, and I agree to be responsible for his/her behavior and safety during this event. Child’s Name

Parent or Guardian’s signature

Address City

State

Zip

Date

Approved as to form by Rita R. Woltz, System Counsel for the VCCS, February 2005.

COMMITMENT FORM Career Exploration Summer Camp 2014 I, the undersigned, agree to participate in the 2014 Career Exploration Summer Camp, July 7th-July 11th, for Caroline and Stafford County Public Schools. I will attend all sessions, participate in all activities, and exhibit appropriate and acceptable behavior at all times. I understand that failure to complete and return this form will forfeit my opportunity to attend the Summer Camp.

Student’s signature

Parent or Guardian’s signature

Photography/Videotaping of Students at the Career Exploration Summer Camp Students may be photographed and videotaped while participating in the Career Exploration Summer Camp activities. Photos and video may be used in presentations made by the students. However, these presentations (and any video therein) will be the property of Germanna Community College (GCC), and will only be shared on the last day of camp. Photos may be shared with local newspapers or used by Mary Washington Healthcare, Gold’s Gym and GCC. If for any reason you do not wish your child’s photos or video containing your child to be used, please inform us so that we can exclude your child’s image from photography and videotaping. This form must be returned on the next day of camp if you are requesting that your child not be photographed or videotaped.

______ I request that my child not be photographed or videotaped.

Student’s name:____________________________

Parent or Guardian’s printed name:_______________________________

Parent or Guardian’s signature: Please return completed applications by May 23, 2014 to: Natasha Bryant: Dual Enrollment Germanna Community College 2130 Germanna Highway Locust Grove, VA 22508 Fax: 540-423-9176 For questions or concerns feel free to call me at 540-423-9131 or email me at [email protected]