Student Participant Health Form

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Gertrude Green
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1 Participant Name: First Male Imagine Tomorrow Washington State University PO Box Pullman, WA Last Female Birth Age on arrival at program Month/Day/Year To Parent(s)/Guardian(s): Please follow the instructions below. Attach additional information if needed Complete pages 1, 2 and 3 of this form and make a copy for yourself. Send the original, signed form to the program by the requested date. Street Address City State Zip Code Parent/guardian with residential placement and/or decision-making authority in the event of illness or injury: Relationship Name: to Participant: Preferred Phones: ( ) ( ) Home Address: (If different from above) Street Address City State Zip Code Second parent/guardian with legal custody to be contacted in case of illness or injury: Relationship Name: to Participant: Preferred Phones: ( ) ( ) Relationship Name: to Participant: Preferred Phones: ( ) ( ) Allergies: No known allergies. This participant is allergic to: Food Medicine The environment (insect stings, hay fever, etc.) Other (Please describe in detail what the participant is allergic to and the reaction seen. Please describe preventative or responsive measures. This participant has a life-threatening allergy. An emergency care plan signed by physician is required. Diet, Nutrition: This participant eats a regular diet. This participant eats a vegetarian diet. (Describe details below.) This participant has special food needs. (Please describe below.) My child is up-to-date on his/her immunizations and tetanus shots as required by state law. My child has an immunization exemption on file with his/her school. I understand and accept the risks to my child from not being fully immunized. Restrictions: I have reviewed the program and activities of Imagine Tomorrow and feel the student can participate without restrictions. I have reviewed the program and activities of Imagine Tomorrow and feel the student can participate with the following restrictions or adaptations. (Please describe below.) Last General Health Information: Note: It is strongly recommended that parents/legal guardians consult a physician prior to allowing their child to participate in physical activity. Are there any medical concerns that the program staff should be aware of? Attach additional information if needed. First Immunizations: Last Additional parent/guardian to be contacted in case of illness or injury: Middle Participant Home Address : First Mail this form to the address below by April 18, Middle School Name and State: Advisor Name: Attendance dates: from: to Participant Name: (For Program Use): Cabin or Group Session Code(s) Student Participant Health Form

2 School Name and State: Student Participant Health Form Advisor Name: First Participant Name: First Middle Last Birth : Month/Day/Year Last Medication: Unfortunately, we are unable to administer medication to children. If your child requires a dosage during program hours, please make appropriate arrangements. Medication is any substance a person takes to maintain and/or improve their health. This includes vitamins and natural remedies. All medications must be in their original containers. Prescriptions must have the child s name and how the medication should be given printed on the prescription container. Please send only those medications that are necessary. This participant will not take any daily medications while attending the activities. This participant will take the following daily medication(s) while attending the activities. 1 Name of medication started Reason for taking When it is given Amount or dose given How it is given Breakfast Lunch Dinner Other time: Breakfast Lunch Dinner Other time: Breakfast Lunch Dinner Other time: Comments: Does the participant require reasonable accommodation for a disability in order to access or be part of the activities? What have we forgotten to ask? Please provide in the space below any additional information about the participant s health that you think important or that may affect his or her ability to fully participate in the program. Attach additional information if needed. This health history is correct and accurately reflects the health status of the participant to whom it pertains. The person described has permission to participate in all program activities except as set forth by parent/guardian and/or an examining physician. If you fail to advise WSU of a medical condition, risks to your child may increase. I understand the information on this form will be shared on a need to know basis with WSU staff and volunteers. I give permission to photocopy this form. In addition, the health care provider has permission to obtain a copy of my child s health record from providers who treat my child and these providers may talk with the program s staff about my child s health status. Signature of Primary Residential Parent/Guardian: Parent/Guardian Name: Relationship to Participant: : Parents/Guardians: Keep a copy for your records. Page 2/3 1. Note: These provisions regarding administration of medication shall not abrogate minors rights to provide their own consent to certain services under Washington law.

3 School Name and State: Student Participant Health Form Advisor Name: First Last Participant Name: First Middle Last Birth : Month/Day/Year Individual Health Record (For Program Use Only) Initial Screening /Time: Initials: Notes (Provide date/time and initial all entries): Medication (Provide date/time, type/amount of medication, and initial all entries): Exit Note (Check one of the following): Left program this day with no reported illness or injury symptoms. Left program this day with the following problem/concern: Page 3/3 /Time: Initials:

4 Emergency Medical Release Imagine Tomorrow Student Participant In an emergency requiring medical attention or a situation reasonably believed by Washington State University (WSU) authorized agents including Imagine Tomorrow staff to be an emergency, I authorize WSU and its authorized agents to obtain emergency medical care for me/my child. I will be responsible for any expenses incurred in so doing, including but not limited to care by health care professionals, hospital care, and ambulance or other services. In addition, the health care provider has permission to obtain a copy of my/my child s health record from providers who treat me/my child, and these providers may talk with the program s staff about my/my child s health status. NOTE: Minors may consent to certain services in Washington. I hold harmless and agree to indemnify Washington State University, its authorized agents and employees and the staff of Imagine Tomorrow from decisions to seek emergency treatment. Please complete the following: Imagine Tomorrow Student Competitor: of Birth: School Name and State: Advisor Name: Parent or Guardian: Address: _ City: State: Zip: Phone: ( ) First Last Health-Care Providers: Name of participant s primary doctor(s): Phone: ( ) Name of dentist(s): Phone: ( ) Name of orthodontist(s): Phone: ( ) Additional health care provider(s) name(s) and contact numbers:

5 Medical Insurance Information: This participant is covered by family medical and/or hospital insurance Yes No Primary Insurance Company Policy Number _ Subscriber Insurance Company Phone Number ( ) _ Secondary Insurance Company Policy Number Subscriber Insurance Company Phone Number ( ) Name of another person to contact in case of emergency if you are not available: Phone: ( ) Relationship to participant: I voluntarily sign this authorization in consideration for permission for my child to participate in Imagine Tomorrow. I have read it, and I understand its content and significance. Signature of Parent/Guardian (for participant less than 18 years of age) Signature of Imagine Tomorrow Student Competitor (for participant 18 years of age or older) Witness Signature Mail this completed form to the address below by April 18, Imagine Tomorrow Washington State University PO Box Pullman, WA

6 IMAGINE TOMORROW ACTIVITIES For Parents or Guardians of Participants Under 18 Years of Age May 20-22, 2016 ASSUMPTION OF RISK I understand that there are risks in participating in recreational activities and educational workshops at the Imagine Tomorrow activities at Washington State University (WSU). In consideration for and as a condition of being allowed to participate in this voluntary activity, I agree to take full responsibility for any and all risks that exist, including the risk of death or injury to my child or loss or damage to my property. I understand that there may be risks that WSU cannot predict or foresee, and I also assume full responsibility for those risks. Risks in participating in the Imagine Tomorrow activities (including touring campus facilities and participating in activities in the Recreation Center), include, but are not limited to: temporary or permanent muscle soreness, sprains, strains, cuts, abrasions, bruises, ligament and/or cartilage damage, orthopedic damage, head, neck or spinal injuries, loss or use of arms and/or legs, eye damage, disfigurement, burns, drowning or death. I also recognize that there are both foreseeable and unforeseeable risks of injury or death that may occur as a result of traveling to or from the Imagine Tomorrow activities that cannot be specifically listed. Further, I recognize that the actions of other participants in the activity may cause harm or loss to my child or property. RELEASE OF LIABILITY I release the state of Washington, the Regents of WSU, WSU, any subdivision or unit of WSU, its officers, employees, and agents, from any and all liability, claims, costs, expenses, injuries and/or losses to person or property, which I may sustain and/or sustain as a result of death or injury of my child, as a result of or connected with participation in the above event. My child s participation includes, but is not limited to, travel to and from the event in a private or public vehicle, any activity connected with the event itself, and use of state equipment or facilities for the event whether on or off WSU property. I have carefully read this document, understand its contents and am fully informed about this program and circumstances. I am aware that this document is a contract with WSU and the program sponsors. I sign it freely and voluntarily. DATED THIS DAY of, 20. Name of Parent or Guardian (Printed) Name of Minor (Printed) School Name and State Advisor's Name (Printed) Parent's/Guardian's Signature Witness's Name (Printed) Witness s Signature Mail this completed form to the address below by April 18, Imagine Tomorrow Washington State University PO Box Pullman, WA

7 COMPETITOR CODE OF CONDUCT Imagine Tomorrow offers an environment in which competitors live, play, and learn as part of a greater community. Competitor attitude and behavior are critical to the success of the Imagine Tomorrow community and each individual makes a difference in the quality of the competition experience. In order to create a community atmosphere, competitors agree to follow these behavioral guidelines during their competition experience. Competitors and parents/guardians must read and sign this agreement prior to Imagine Tomorrow attendance. As a competitor, the below-signed person agrees and his or her parent(s)/guardian(s) confirm: I will treat everyone in the competition community with respect at all times, including showing respect for another s personal belongings, privacy, and feelings. I understand that harassment and other forms of discrimination based upon race, color, religion, creed, sex, national origin, age, sexual orientation or expression, disability or veteran status violate federal and state law and/or Washington State University policy, and they will not be tolerated. I will respect the competition and University s facilities and equipment and not take or destroy competition/university property. I will not use obscene or foul language or gestures or make reference to violent offensive actions. I will not engage in any activity which may put me, other competitors, or staff at risk. I agree to abide by the rules and regulations of the competition and agree to follow directions and guidance provided by the competition staff. I will dress according to my school s dress code policy. I will observe the curfew hours that have been established. I will remain on my floor between 9:55 p.m. and 7:00 a.m. and remain in my room after lights out (10:00 p.m.). Noise shall be limited as to respect others. Exceptions to this provision may occur for special activities as part of the Imagine Tomorrow program. I will stay with my advisor or competition staff at all times. If the competitor fails to abide by these behavioral expectations, the team s advisor will be notified and asked to assist in helping the competitor make more positive choices and follow the expectations as agreed. If competitor s behavior does not improve, the competitor will be asked at the program s discretion to leave the competition and the team disqualified from participating. Parents are responsible for their competitors travel to and from the competition. Page 1 of 2

8 The following behaviors are considered very serious and will result in immediate expulsion from the competition, and misconduct believed to be criminal in nature (i.e., violations of law) will be reported to law enforcement: Any crime, including use, possession, or distribution of weapons, alcohol, drugs, tobacco, or any other illegal product. If a competitor is authorized to possess prescription medication, it must be listed on the medical form or possession of the medication will be considered in violation of the code of conduct. Assault and/or physical abuse of any kind including hitting, kicking, biting or pushing another competitor, staff member or other person. Failure to follow staff instructions thereby resulting in situations that put the competitor, other competitors, or staff in physical danger. Leaving an activity without the permission of the staff member supervising the area or activity. Verbal abuse of another competitor, staff member and/or other person. A competitor threatening to harm him or herself or others or engaging in actions reasonably likely to result in harm to self or others. I, _ (competitor s name), have read and understand these behavioral expectations, including provisions for immediate expulsion as stated in this document. I agree to abide by them at all times during my stay at the competition. Competitor Signature I, (Parent/Guardian Name), have read and understand these behavioral expectations and agree to them, including provisions for immediate expulsion for the reasons stated in this document. Furthermore, I have discussed these expectations with my child and he/she has agreed to abide by them at all times during his/her participation in Imagine Tomorrow. Parent/Guardian Signature Competitior Name School Name and State Advisor Name First, Last Page 2 of 2 Mail this completed form to the address below by April 18, Imagine Tomorrow Washington State University PO Box Pullman, WA

9 Image and Voice Recording Consent Imagine Tomorrow - Student Participant _ (print student s name) and his/her parent or guardian, hereby grant permission to Washington State University (WSU) to be photographed or otherwise have images or voice recordings made (including but not limited to digital photographs, video or digital moving images and/or voice recordings), for WSU publication or promotional purposes in any medium (including but not limited to print media, newspaper, television, video, motion picture, or Web site on the Internet). I additionally consent to the use of the student s name and/or interview comments in connection with WSU publication or promotional purposes in print media, newspaper, television, video, motion picture, or Web site on the Internet. We understand that consent to use of the student participant s likeness or voice recordings is not a condition of participating in the activity and that consent can be refused without any impact in the ability to fully participate in the program. No inducements or promises beyond our acceptance of an opportunity to promote WSU and its programs have been given to the persons signing below. Any other use of images and/or recordings, my name, and/or interview comments requires advance permission. We understand that we can revoke this consent at any time upon notice to WSU, at which time either or both of us will sign a copy of the denial (below) for use of images or voice recordings. We agree to use of digital images or voice recordings as set forth above: Signature of Parent/Guardian (for participant less than 18 years of age) Signature of Witness (required) Signature of Imagine Tomorrow Student Competitor Signature of Witness (required) School Name and State Advisor Name (First, Last) We do not agree to use of digital images or voice recordings as set forth above: Signature of Parent/Guardian (for participant less than 18 years of age) Signature of Witness (required) Signature of Imagine Tomorrow Student Competitor Signature of Witness (required) Mail this completed form to the address below by April 18, Imagine Tomorrow Washington State University PO Box Pullman, WA

10 Special Dietary Needs Form and Waiver University Housing & Dining PO Box Streit Perham Administrative Suites Pullman, WA , (509) Camp/Conference Attending: s Attending: to PARTICPANT INFORMATION Participant Name: Participant Age: Birth : Phone: (cell/home) Parent or Guardian Name: Relationship to Participant: Phone (Cell): Work: Home: _ FOOD ALLERGY(S)/INTOLERANCES Please provide medical documentation describing the dietary restrictions due to the food allergy and/or intolerance, from the Participant s Physician (MD or DO). Check all that apply: *FOOD ALLERGY Dairy Soy Eggs Peanuts Tree Nuts Fish Shellfish Wheat (do not check this for celiac disease or gluten sensitivity) Other, please list: *FOOD INTOLERANCE Gluten (celiac disease or non celiac gluten sensitivity, includes wheat, barley, oats, rye) Lactose MSG Other, please list: Other Special Diet needs or restrictions (i.e., Diabetes, IBS, other): A minimum of two (2) weeks prior to the camp/conference, Camp/Conference Participants or the Participant s Legal Guardian is required to contact Interim Dining Service s Dietitian, Hsiu Pow Hwang, RD at , hsiupow@wsu.edu. Dining Services will provide the participant menus in advance to assist in planning meals. Dining Services will make every attempt to meet special diet and food allergy needs, but cannot guarantee food service for all food allergies.

11 University Housing and Dining Services does not provide assistance or administer injections due to allergic reactions and does not carry or provide stock epinephrine in any dining hall. Dietary Needs Questionnaire Please answer the following questions to better help us with your needs: 1. What are the preferred food substitutions, if any? (soy butter for peanut butter, gluten free breads, soy milk, etc.): 2. What types of contact will cause a reaction? Airborne Trace Cross Contact Actual ingestion of food Other Please explain reaction: 3. Does the Participant understand the food allergy and what needs to be done to manage it? 4. Has the Participant ever attended camp or eaten meals outside the home? If yes, how were the meals handled? 5. Is there any other information you would like to share to help us meet the Participant s needs?

12 Washington State University Dining Services makes every attempt to identify ingredients that may cause allergic reactions for those with food allergies. Every effort is made to instruct our food productions staff on the severity of food allergies. In addition, we label items with possible allergen containing ingredients; however, there is always a risk of contamination. There is also a possibility that manufacturers of the commercial foods we use could change the formulation at any time, without notice. Customers concerned with food allergies need to be aware of this risk. Dining Services is not responsible for adverse reactions to foods consumed, or items one may come in contact with while eating at any University establishments. Students with food allergies are encouraged to contact Dining Services at and/or the Dietitian at hsiupow@wsu.edu or for additional information and/or support. By signing this, I am certifying I understand the information contained in this form and I verify the information provided is true and correct. I release and hold harmless the state of Washington, the Regents of WSU, WSU, any subdivision or unit of WSU, its officers, employees, and agents, from any and all liability, claims, costs, expenses, injuries and/or losses, that I may sustain as a result of, or connected with my participation in the above activities. I have carefully read this document, understand its contents, and am fully informed about circumstances described in this document, as well as those that are not anticipated. Signature : Printed Name Signature of Parent/Guardian (if under 18) : Mail this completed form to the address below by April 18, Imagine Tomorrow Washington State University PO Box Pullman, WA

Student Participant Health Form

Student Participant Health Form Participant Name: Male Female Birth Age on arrival at program Month/Day/Year To Parent(s)/Guardian(s): Please follow the instructions below. Attach additional information if needed. 1. 2. Complete pages