2017 Anatomy Camp APPLICATION MATERIALS CHECKLIST

Transcription

1 2017 Anatomy Camp APPLICATION MATERIALS CHECKLIST Please use the form as a checklist for your summer registration materials. Obtain all required parent or guardian signatures. Any forms with missing signatures will be returned to you and your registration will be considered incomplete. These forms are required for your participation in the program and the sooner they are completed the better. Student Name: Camp Session Requested: ALL SIGNED FORMS must be postmarked by July 1, 2017 Form: Student Contract Camper Health History Forms Recommendations for Licensed Medical Personnel Form Emergency Contact Form CSU Release from Liability and Risk Waiver Roommate Request Form Whitewater Rafting Consent Form Signature(s) Included Forms rec d/complete ( office use only) Please Return Completed Forms and this Checklist BY MAIL: -or- or Fax to: Heather Hall 1680 Campus Delivery anatomycamp@colostate.edu Colorado State University Fort Collins, CO *Please include cover sheet

2 STUDENT CONTRACT A high degree of responsibility and maturity is expected of our students. It is important for reasons of safety and program effectiveness that certain standards of behavior be followed by all students. Your signature on this form indicates that you have read, under stand, and agree to follow all of the rules listed below. Violation of any of the rules may be cause for expulsion from the program or for other appropriate disciplinary action to be determined by staff. 1) All students must attend all classes and activities. Absence or tardiness is unacceptable except for excused medical emergencies or when arrangements cannot be made outside of class time. Students must inform the Camp Directors in advance in order for the excuse to be considered valid. *Note: Excused absence must be arranged on an individual basis, and must be specifically authorized by the Camp Directors. 2) The use or possession of drugs, alcohol, or weapons while in the Anatomy Camp at Colorado State University is not permitted under any circumstances, and will be cause for immedi ate expulsion. This includes being in the company of another person who is using or is in possession of drugs, alcohol, or weapons. CSU Police department will be contacted to handle any such occurrences. 3) Curfew: On-floor is 10 p.m., and in-room is 10:30 p.m. Quiet hours are from 10 p.m. to 7 a.m. 4) No student may ride in or drive any personal vehicle during the camp, unless arrangements are made in advance with the Camp Directors 5) Students are not allowed to leave campus alone at any time unless accompanied by a staff member or parent/guardian with prior approval. 6) Students are expected to behave in a respectful, responsible, and non-disruptive fashion at all times, and are expected to exercise sound judgment regarding behavior. Any questions about particular situations should be addressed to camp staff in advance. 7) Students are not to engage in any verbal, physical or sexual harassment of other participants, counselors, leaders, or any other people, and will be cause for immediate expulsion. This includes harassing or intimidating others via text, electronic mail, newsgroups or web pages while using CSU s Computing and Network Resources. 8) Students must follow all rules of anatomy and dissection labs without question, or will be cause for immediate expulsion (see separate document for rules). 9) Students must follow all rules and terms of dormitories and student recreation center, including: a) I understand that I am liable as an individual or as part of the Anatomy Camp group for any damage that I, or we, as a group may cause in and around the residence hall, classroom or visited facility and agree to pay for the replacement or restoration of the property. b) I understand that I am responsible for my room key and, if lost, I will be charged $65.00 for the replacement of the lock and key.

3 c) I understand that UNDER NO CIRCUMSTANCES may any screen be removed from any window. If a screen is tampered with, damaged, or removed, I will be charged $ ) All students will have access to CSU s computer networks. In consideration of being allowed to use the University's central computer and network services, students agree to refrain from any illegal activity or for any activity prohibited by CSU s Acceptable Use Policy for Computing and Networking Resources. If you have questions regarding illegal activity, inappropriate or destructive actions pertaining to computing resources, you may view CSU s complete policy at: Consequences Violation of the camp rules will result in incident-appropriate disciplinary action as determined by camp staff and camp directors. Campers may be removed from individual activities, removed from dormitories, or expelled from camp at the expense of the parents. Please read and sign the following statement: I, ( student), have read the rules of the Anatomy Camp at Colorado State and I understand the consequences for breaking the aforementioned rules of the camp. Student Signature: DATE Parent/Guardian: DATE Parent/Guardian: DATE

4 CAMPER HEALTH HISTORY FORM1 Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on School Health, & Association of Camp Nurses Mail this form to the address below by (date) Camper Home Address: Street Address City State Zip Code Parent/guardian with legal custody to be contacted in case of illness or injury: Relationship Name: to Camper: Preferred Phones: ( ) ( ) Home Address: (If different from above) Street Address City State Zip Code Second parent/guardian or other emergency contact: Relationship Name: to Camper: Preferred Phones: ( ) ( ) Additional contact in event parent(s)/guardian(s) can not be reached: Relationship Name: to Camper: Preferred Phones: ( ) ( ) Allergies: No known allergies. This camper is allergic to: Food Medicine The environment (insect stings, hay fever, etc.) Other (Please describe below what the camper is allergic to and the reaction seen.) Diet, Nutrition: Restrictions: This camper eats a regular diet. This camper eats a regular vegetarian diet. This camper is lactose intolerant. This camper is gluten intolerant. Other, please explain in space. I have reviewed the program and activities of the camp and feel the camper can participate without restrictions. I have reviewed the program and activities of the camp and feel the camper can participate with the following restrictions or adaptations. (Please describe below.) Medical Insurance Information: This camper is covered by family medical/hospital insurance Yes No Include a copy of your insurance card if appropriate; copy both sides of the card so information is readable. Insurance Company Policy Number Subscriber Dates will attend camp: from to Month/Day/Year Month/Day/Year Camper Name: First Middle Last Male Female Birth Date Age on arrival at camp: Month/Day/Year To Parent(s)/Guardian(s): Please follow the instructions below. Attach additional information if needed. 1) Complete pages 1, 2 and 3 of this form (FORM 1) and make a copy. 2) Send the original, signed FORM 1 to camp by the requested date. 3) Complete the top of FORM 2 (CAMPER HEALTH-CARE RECOMMENDATIONS) and provide the copy of FORM 1 with FORM 2 to your child s health-care provider for review and completion. 4) After it has been completed and signed by your child s health-care provider, return FORM 2 to camp by the requested date. InsuranceCompany Phone Number ( ) Parent/Guardian Authorization for Health Care: This health history is correct and accurately reflects the health status of the camper to whom it pertains. The person described has permission to participate in all camp activities except as noted by me and/or an examining physician. I give permission to the physician selected by the camp to order x-rays, routine tests, and treatment related to the health of my child for both routine health care and in emergency situations. If I cannot be reached in an emergency, I give my permission to the physician to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for this child. I understand the information on this form will be shared on a need to know basis with camp staff. I give permission to photocopy this form. In addition, the camp 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 Custodial Relationship Parent/Guardian Date: to Camper: If for religious or other reasons you cannot sign this, contact the camp for a legal waiver which must be signed for attendance. Page 1/4 First Middle Last Camper Name (For Camp Use) Cabin or Group (For Camp Use) Session Code(s):

5 CAMPER HEALTH HISTORY FORM 1 Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on School Health, & Association of Camp Nurses Camper Name: First Middle Last Birth Date: Month/Day/Year Immunization History: Provide the month and year for each immunization. Starred ( ) immunizations must include date to meet ACA Standard. Copies of immunization forms from health-care providers or state or local government are acceptable; please attach to this form. Immunization Dose 1 Month/Year Diptheria, tetanus, pertussis (DTaP) or (TdaP) Tetanus booster (dt) or (TdaP) Mumps, measles, rubella (MMR) Polio (IPV) Haemophilus influenzae type B (HIB) Pneumococcal (PCV) Hepatitis B Dose 2 Month/Year Dose 3 Month/Year Dose 4 Month/Year Dose 5 Month/Year Most Recent Dose Month/Year Hepatitis A Varicella (chicken pox) Meningococcal meningitis (MCV4) Had chicken pox Date: Tuberculosis (TB) test Date: Negative Positive If your camper has not been fully immunized, please sign the following statement: I understand and accept the risks to my child from not being fully immunized. Signature of Custodial Relationship Parent/Guardian: Date: to Camper: Medication: This camper will not take any daily medications while attending camp. This camper will take the following daily medication(s) while at camp: Medication is any substance a person takes to maintain and/or improve their health. This includes vitamins & natural remedies. Please review camp instructions about required packaging/containers. Many states require original pharmacy containers with labels which show the camper s name and how the medication should be given. Provide enough of each medication to last the entire time the camper will be at camp. Name of medication Date started Reason for taking it When it is given Amount or dose given How it is given Breakfast Lunch Dinner Bedtime Other time: Breakfast Lunch Dinner Bedtime Other time: Breakfast Lunch Dinner Bedtime Other time: Breakfast Lunch Dinner Bedtime Other time: The following non-prescription medications may be stocked in the camp Health Center and are used on an as needed basis to manage illness and injury. Cross out those the camper should not be given. Acetaminophen (Tylenol) Phenylephrine decongestant (Sudafed PE) Antihistamine/allergy medicine Diphenhydramine antihistamine/allergy medicine (Benadryl) Sore throat spray Lice shampoo or cream (Nix or Elimite) Calamine lotion Laxatives for constipation (Ex-Lax) Ibuprofen (Advil, Motrin) Pseudoephedrine decongestant (Sudafed) Guaifenesin cough syrup (Robitussin) Dextromethorphan cough syrup (Robitussin DM) Generic cough drops Antibiotic cream Aloe Bismuth subsalicylate for diarrhea (Kaopectate, Pepto-Bismol) Copyright 2014 by American Camping Association, Inc. Page 2/4 Rev.1/2014 LEE/EAW

6 CAMPER HEALTH HISTORY FORM 1 Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on School Health, & Association of Camp Nurses Camper Name: First Middle Last Birth Date: Month/Day/Year General Health History: Check Yes or No for each statement. Explain Yes answers below. Has/does the camper: 1. Ever been hospitalized?... Yes No 11. Had fainting or dizziness?... Yes No 2. Ever had surgery? Yes No 12. Passed out/had chest pain during exercise?.... Yes No 3. Have recurrent/chronic illnesses? Yes No 13. Had mononucleosis ( mono ) during the past 12 months?... Yes No 4. Had a recent infectious disease? Yes No 14. If female, have problems with periods/menstruation?.... Yes No 5. Had a recent injury? Yes No 15. Have problems with falling asleep/sleepwalking?... Yes No 6. Had asthma/wheezing/shortness of breath?... Yes No 16. Ever had back/joint problems? Yes No 7. Have diabetes? Yes No 17. Have a history of bedwetting?.... Yes No 8. Had seizures?... Yes No 18. Have problems with diarrhea/constipation?... Yes No 9. Had headaches?... Yes No 19. Have any skin problems?... Yes No 10. Wear glasses, contacts, or protective eyewear? Yes No 20. Traveled outside the country in the past 9 months?... Yes No Please explain Yes answers in the space below, noting the number of the questions. For travel outside the country, please name countries visited and dates of travel. Mental, Emotional, and Social Health: Check Yes or No for each statement. Has the camper: 1. Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (AD/HD)?... Yes No 2. Ever been treated for emotional or behavioral difficulties or an eating disorder?... Yes No 3. During the past 12 months, seen a professional to address mental/emotional health concerns?.... Yes No 4. Had a significant life event that continues to affect the camper s life?... Yes No (History of abuse, death of a loved one, family change, adoption, foster care, new sibling, survived a disaster, others) Please explain Yes answers in the space below, noting the number of the questions. The camp may contact you for additional information. Health-Care Providers: Name of camper s primary doctor(s): Name of dentist(s): Name of orthodontist(s): Phone: ( ) Phone: ( ) Phone: ( ) What Have We Forgotten to Ask? Please provide in the space below any additional information about the camper s health that you think important or that may affect the camper s ability to fully participate in the camp program. Attach additional information if needed. Parents/Guardians: STOP here. The rest of this is form is completed when the camper arrives at camp. Keep a copy for your records. Copyright 2014 by American Camping Association, Inc. Page 3/4 Rev.1/2014 LEE/EAW

7 CAMPER HEALTH HISTORY FORM 1 Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on School Health, & Association of Camp Nurses Camper Name: First Middle Last Birth Date: Month/Day/Year Individual Health Record (For Camp Use Only) Initial Screening Date/Time: Initials: Screening has been conducted according to camp protocol and significant findings noted as follows: A. Any signs/symptoms of illness or injury upon arrival?... No Yes as noted below B. History of exposure to communicable disease?... No Yes as noted below C. Additions or corrections to information on this health history?... No Yes as noted below D. Medication given to health-care staff?... No Yes as noted below E. Any signs/symptoms of head lice?... No Yes as noted below Provider notes: (date/time/initial all entries) Exit Note: Check one of the following: Left camp this day with no reported illness or injury symptoms. Left camp this day with the following problem/concern: This person was told about the problem and instructed about follow-up as noted above: Date/Time: Initials: Copyright 2014 by American Camping Association, Inc. Page 4/4 Rev.1/2014 LEE/EAW

8 Recommendations for Licensed Medical Personnel FORM 2 Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on School Health, & Association of Camp Nurses Mail this form to the address below by (date) The following non-prescription medications are commonly stocked in camp Health Centers and are used on an as needed basis to manage illness and injury. Medical personnel: Cross out those items the camper should not be given. Acetaminophen (Tylenol) Ibuprofen (Advil, Motrin) Phenylephrine (Sudafed PE) Pseudoephedrine (Sudafed) Chlorpheneramine maleate Guaifenesin Dextromethorphan Diphenhydramine (Benadryl) Generic cough drops Chloraseptic (Sore throat spray) Lice shampoo or scabies cream (Nix or Elimite) Diet, Nutrition: Eats a regular diet. Has a medically prescribed meal plan or dietary restrictions:(describe below) The camper is undergoing treatment at this time for the following conditions: (describe below) None. Medication: No daily medications. Will take the following prescribed medication(s) while at camp: (name, dose, frequency describe below) Other treatments/therapies to be continued at camp: (describe below) None needed. Do you feel that the camper will require limitations or restrictions to activity while at camp? No Yes If you answered Yes to the question above, what do you recommend? (describe below attach additional information if needed) I have reviewed the CAMPER HEALTH HISTORY FORM (FORM 1), and have discussed the camp program with the camper s parent(s)/guardian(s). It is my opinion that the camper is physically and emotionally fit to participate in an active camp program (except as noted above.) Name of licensed provider (please print): Signature: Title: Office Address Street City State Zip Code Telephone: ( ) Copyright 2014 by American Camping Association, Calamine lotion Bismuth subsalicylate (Pepto-Bismol) Laxatives for constipation (Ex-Lax) Hydrocortisone 1% cream Topical antibiotic cream Calamine lotion Aloe To Parent(s)/Guardian(s): Complete this section and give this form (FORM 2) and a copy of your completed CAMPER HEALTH HISTORY FORM (FORM 1) to your child s health-care provider for review. Dates will attend camp: from to Month/Day/Year Month/Day/Year Camper Name: First Middle Last Male Female Birth Date Age on arrival at camp Month/Day/Year Camper home address: City State Zip Code Custodial parent(s)/guardian(s) phone: ( ) ( ) Parent(s)/guardian(s) stop here. Rest of form to be completed by medical personnel. Medical Personnel: Please review the CAMPER HEALTH HISTORY FORM (FORM 1) and complete all remaining sections of this form (FORM 2). Attach additional information if needed. Physical exam done today: Yes No (If No, date of last physical: ) Month/Day/Year ACA accreditation standards specify physical exam within the last 12 months. Weight: lbs Height: ft in Blood Pressure / Allergies: No Known Allergies To foods (list): To medications: (list): To the environment (insect stings, hay fever, etc. list): Other allergies: (list): Describe previous reactions: Date: Inc. Rev. 1/14 LEE/EAW First Middle Last Camper Name (For Camp Use) Cabin or Group (For Camp Use) Session Code(s):

9 Emergency Contact and Medical Information for a Student Student s Name Date of Birth Sex M F Parent s/guardian s Name Parent s/guardian s Name Home Phone Work Phone Home Phone Work Phone Address Address City, ST ZIP Code City, ST ZIP Code Alternative Emergency Contacts Primary Emergency Contact Secondary Emergency Contact Home Phone Work Phone Home Phone Work Phone Address Address City, ST ZIP Code City, ST ZIP Code Medical Information Physician s Name Phone Number Insurance Company Policy Number Allergies/Special Health Considerations I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached in the case of an emergency. Parent s/guardian s Signature Date I give permission for my child to go on field trips. I release Colorado State University and individuals from liability in case of accident during activities related to Anatomy Camp, as long as normal safety procedures have been taken. Parent s/guardian s Signature Date Witness Signature Date

10 ANATOMY CAMP AT COLORADO STATE UNIVERSITY RELEASE LIABILITY AND RISK WAIVER READ THIS DOCUMENT COMPLETELY BEFORE SIGNING. ITS EFFECT IS TO RELEASE THE UNIVERSITY FROM ANY LIABILITY RESULTING FROM YOUR CHILD S PARTICIPATION IN THE ABOVE-NAMED ACTIVITIES AND WAIVES ALL CLAIMS FOR DAMAGES OR LOSSES AGAINST THE UNIVERSITY. Name of Participant/s RELEASE FROM RESPONSIBILITY, ASSUMPTION OF RISK, AND WAIVER In consideration of my child being permitted by Anatomy Camp at Colorado State University to participate in the following activities: Transportation to and from Denver International Airport ( if applicable) Staying in on-campus dormitory ( if applicable) Heart, Lung, Brain Dissection Studying and touching Human Cadavers Building Clay Models Swimming and playing sports at the Student Recreation Center and Student Recreation Fields Evening in Old Town Fort Collins ( including transportation to and from) Hiking at Horsetooth State Park (including transportation to and from) White Water Rafting (including transportation to and from) Field Trip to Fort Collins Discovery Museum (including transportation to and from) On-Campus Team Games and Activities I, the undersigned parent/ legal guardian (printed name), exercising my own free choice given my consent for my child to participate voluntarily in the above-named activities, hereby release and discharge, indemnify and hold harmless The State of Colorado, the Board of Governors of the Colorado State University System, Colorado State University, and their members, officers, agents, employees, and any other persons or entities acting on their behalf, and the successors and assigns for any and all of the afore- mentioned persons and entities, against all claims, demands, and causes of action whatsoever, either in law or in equity, relating to injury, disability, death or other harm, to person or property or both, arising from my child s participation in and/or presence at the above listed activities. I acknowledge that I have been informed of hazards and risks which may be associated with my child s participation in the above-named activities;; I understand, accept, and assume those hazards and risks, and waive all claims against The Board of Governors of the Colorado State University System, and Colorado State University, and other entities or persons set forth above. I understand that I am solely responsible for any costs arising out of any bodily injury or property damage sustained through my child s participation in normal or unusual acts associated with the above-named activities. I have had sufficient time to review and seek explanation of the provisions contained above, have carefully read them, understand them fully, and agree to be bound by them. After careful deliberation, I voluntarily give my consent and agree to this Release from Responsibility, Assumption of Risk, and Waiver. Read and acknowledged this day of, 20. I, (printed name), am the parent or legal guardian of the participant/s (Insert name/s here). I have read and understand the provisions of this document, I consent my child participating in the activities described above, and I fully enter into and agree to the above Release from Responsibility, Assumption of Risk, and Waiver. Signature of Parent or Legal Guardian Date

11 2017 Anatomy Camp ROOMMATE REQUEST FORM Personal Contact Information Name: (First) (Last) Phone Number: (Cell) (Home) What state do you currently live in: Personal Compatibility Information Gender: Male Female Year in school (Fall 2016): Where do you attend school? I have the following roommates in mind: (List Names) Personal Attributes: (Please give accurate representation. This information is confidential and is used to make your housing experience the best it can be thus making you happier ) On a scale of 1 to 5, where 1 is do not at all agree and 5 is highly agree, How much do you agree with the following statements: I am very neat I am very outgoing I spend a lot of time studying I am very physically active I like to listen to loud music/tv Describe your hobbies, interests, clubs/organizations, other considerations or special requests: List 3 traits/characteristics you look for in a roommate:

12 J.P. LEGEL, INC. D/B/A A WANDERLUST ADVENTURE RAFTING WARNING, ASSUMPTION OF RISK, RELEASE OF LIABILITY & INDEMNIFICATION AGREEMEN PLEASE READ CAREFULLY BEFORE SIGNING. THIS IS A RELEASE OF LIABILITY & WAIVER OF LEGAL RIGHTS. 1. Definitions. The person who is participating in rafting shall be referred to hereinafter as "Participant". The "Undersigned" means only the Participant when the Participant is age 18 or older OR it means both the Participant and the Participant's parent or legal guardian when the Participant is under the age of 18. "Released Parties" mean J.P. Legel Inc, d/b/a A Wanderlust Adventure or any of its respective successors in interest, affiliated organizations and companies, insurance carriers, agents, employees, representatives, assignees, officers, directors, members, and shareholders. The "Activity" means taking part In rafting, swimming, wading, hiking, climbing on rocks and slopes, portaging and traveling to and from Activity site. 2. Risks of Activity. The Undersigned agree and understand that taking part in the Activity can be HAZARDOUS AND INVOLVES THE RISK OF PHYSICAL INJURY AND/OR DEATH. The Undersigned acknowledge that the Activity is inherently dangerous and fully realize the dangers of participating in the Activity. The risks and dangers of the activity include, but are not limited to: choice of rafting course, negligence of rafting guides, changing weather conditions, changing water conditions, cold water immersion, hidden underwater obstacles, trees or other above water obstacles, slippery terrain, changing and unpredictable currents, drowning, exposure, swimming, overturning, improper use of equipment, jumping off rocks, carrying rafts and other equipment, entrapment of feet or other body parts under rocks or other objects, equipment failure, dehydration, sunburn, driving to and from the Activity site, and mental distress from exposure to any one of the above. THE UNDERSIGNED ACKNOWLEDGE AND UNDERSTAND THAT THE DESCRIPTION OF THE RISKS LISTED ABOVE IS -NOT COMPLETE AND THAT PARTICIPATING IN THE ACTIVITY MAY BE DANGEROUS AND MAY INCLUDE OTHER RISKS. 3. Release, Indemnification, and Assumption of Risk. In consideration of the Participant being permitted to participate in the activity, the Undersigned agree as follows: (a) Release. THE UNDERSIGNED HEREBY IRREVOCABLY AND UNCONDITIONALLY RELEASE, FOREVER DISCHARGE, AND AGREE NOT TO SUE OR BRING ANY OTHER LEGAL ACTION AGAINST THE RELEASED PARTIES with respect to any and all claims and causes of action of any nature whether currently known or unknown, which the Undersigned, or any of them, have or which could be asserted on behalf of the Undersigned in connection with the Participant's participation in the Activity, including, but not limited to claims of negligence, breach of warranty, and/or breach of contract. (b) Indemnification. The Undersigned hereby agree to indemnify, defend and hold harmless the Released Parties from and against any and all liability, cost, expense or damage of any kind or nature whatsoever and from any suits, claims or demands, including legal fees and expenses whether or not in litigation, arising out of, or related to, Participant's participation in the Activity. Such obligation on the part of the Undersigned shall survive the period of the Participant's participation in the Activity. (c) Assumption of Risk. The Undersigned agree and understand that there are dangers and risks associated with the participation in the Activity and that INJURIES AND/OR DEATH may result from participating in the Activity, including, but not limited to the acts, omissions, representations, carelessness, and negligence of the Released Parties. By signing this document, the Undersigned recognize that property loss, injury and death are all possible while participating in the Activity. RECOGNIZING THE RISKS AND DANGERS, THE UNDERSIGNED UNDERSTAND THE NATURE OF THE ACTIVITY AND VOLUNTARILY CHOOSE FOR PARTICIPANT TO PARTICIPATE IN AND EXPRESSLY ASSUME ALL RISKS AND DANGERS OF THE PARTICPATION IN THE ACTIVITY, WHETHER OR NOT DESCRIBED ABOVE, KNOWN OR UNKNOWN, INHERENT, OR OTHERWISE. 4. Minor Acknowledgment. In the case of a minor Participant, the Undersigned parent or legal guardian acknowledges that he/she is not only signing this Agreement on his/her behalf, but that he/she is also signing on behalf of the minor and that the minor shall be bound by all the terms of this Agreement. Additionally, by signing this Agreement as the parent or legal guardian of a minor, the parent or legal guardian understands that he/she is also waiving rights on behalf of the minor that the minor otherwise may have. The Undersigned parent or legal guardian agrees that, but for the foregoing, the minor would not be permitted to participate in the Activity. By signing this Agreement without a parent or legal guardian's signature, Participant, under penalty of fraud, represents that he/she is at least 18 years of age. If signing as the parent or guardian of a minor Participant, signing adults represent that they are a legal parent or guardian of the minor Participant. 5. Medical Care. The UNDERSIGNED represents that the PARTICIPANT is in good health and there are no special problems associated with his/her care. The Undersigned authorize the Released Parties and/or their authorized personnel to call for medical care for Participant or to transport Participant to a medical facility or hospital if, in the opinion of such personnel, medical attention is needed. Undersigned agree to pay all costs associated with such medical care and related transportation. 6. Miscellaneous. THE UNDERSIGNED recognize that helmets and life jackets are required and PARTICIPANT agrees to wear a helmet and life jacket at all times while participating in the ACTIVITY. The PARTICIPANT AGREES to the use of any and all photographs and videos which may be taken of them while on the premise of A Wanderlust Adventure, including all raft trips, by A Wanderlust Adventure, for any purpose whatsoever, without compensation to them. All images shall constitute A Wanderlust Adventure property. The Undersigned further agree and understand: {a) Participant will not engage in any activities prohibited by any applicable laws, statutes, regulations and ordinances; (b) this Agreement shall be governed by the laws of the State of Colorado, and the exclusive jurisdiction for any claim shall be the District Court of Larimer County, Colorado or the federal court of the State of Colorado; (c) this Agreement constitutes the entire agreement between the parties hereto and supersedes any and all prior contracts, arrangements, communications, or representations, whether oral or written, between the parties relating to the subject matter hereof; (d) the Undersigned understand and acknowledge that this Agreement is a contract and shall be binding to the fullest extent permitted by law. If any part of this Agreement is deemed to be unenforceable, the remaining terms shall be an enforceable contract between the parties. It is the intent of the Undersigned's that this agreement shall be binding upon the assignees, subrogors, distributors, heirs, next of kin, executors and personal representatives of the Undersigned. I HAVE CAREFULLY READ THE FOREGOING ASSUMPTION OF RISK, RELEASE OF LIABILITY & INDEMNIFICATION AGREEMENT AND UNDERSTAND ITS CONTENTS. I AM AWARE THAT I AM RELEASING LEGAL RIGHTS THAT OTHERWISE MAY EXIST. Printed Name of Participant Signature of Participant Date Printed Name of Parent/Legal Guardian #1 Signature of Parent/Legal Guardian #1 Date Printed Name of Parent/Legal Guardian #2 Signature of Parent/Legal Guardian #2 Date A d d;::-:-:--: <--> ress Emergency Contact: Telephone ( ) P;:;n ::,.ṅ:;; t ::- ed N ;:- a = m :--: e -;;: /R :;-: e -;- la -: t :- io _ n T _e _ le - p - ho _ n _ e _

13 LABORATORY RULES Unauthorized personnel are not allowed in the laboratory without the permission of the directors and staff. All visitors must be cleared through the directors and/or staff. Authorized personnel include student campers currently enrolled in the camp, the faculty and staff associated with the course and maintenance personnel. When you have finished studying with the cadaver, please ensure that the cadaver is fully covered. Cadavers assigned to other students may be uncovered only by permission of those students, or by faculty. NO cameras are allowed in the laboratory. NO photos are to be taken at any time of the cadavers or vital organs. NO cadaver tissue can be taken from the laboratory at any time. Smoking, eating, or drinking is NOT permitted in the laboratory. At all times, please maintain a respectful attitude towards the cadavers. They have been donated for your benefit. Please tidy up before you leave the laboratory. This includes, but is not limited to, W117/W202/W111. Clean the area around your table or gurney and your gurney itself. Remove and clean all used tools. Failure to clean your gurney may result in loss of access to the laboratory for future labs. Please wipe up any spills on the floor immediately, as the fluid makes the floor very slippery and hazardous. Garments worn in the laboratory must be washed at frequent intervals. Scrubs provided by the camp must be worn at all times while in lab. Shoes worn in the laboratory must adequately cover the top of the foot. Gloves must be worn by all persons handling cadavers. Protective eye wear is recommended. Any injuries incurred in the laboratory should be reported immediately to staff members. THANK YOU FOR YOUR COOPERATION!

14 INFORMATION FOR PARENTS Camp Contact Information: If you need to contact the camp directors for any reason, please call Heather Hall at or Tod Clapp at If you can t get a hold of anyone at those two numbers, you can also call the main office numbers: We will have also have an emergency cell phone, which will be activated just prior to the start of camp. We will send you the number to that phone when we send you more details about arrival at camp. Accommodations: Campers will be staying in Summit Hall ( in the enhanced suite double rooms. Camp staff will assign roommates based on common interests. Please have your child take time and consideration when filling out the roommate request form. Dining: Campers will be dining at Ram s Horn at Academic Village. Our showcase facility, Ram s Horn dining center features 8 different food venues including a Mongolian Grill, Tex-Mex station, pasta, deli, salad bar, and more. If campers would like snacks in their dorm room, they can certainly bring some from home or they can purchase in one of CSU s many convenience stores on campus. Transportation to and from the Airport: Denver International Airport is the closest major airport to Colorado State University. If your child is flying in, please have their flights arrive in Denver by 10:30 am at the latest on Sunday. The shuttle will leave promptly at 12:00pm. If you can t make that work, please contact camp staff and we will help you make alternative arrangements for campers to get to camp. Your child will be met by a camp staff representative at the airport who will help your student get on the right shuttle to campus. Once we see how many students we will be shuttling from the airport, we will contact you with more specific details. Dorm Check-In: For those students not flying in to DIA, please plan to arrive between 12-1 p.m. on Sunday and check-in to Summit Hall. Electronics:

15 Your child is welcome to bring personal electronics and leave them in their dorm room during the day. They will be given a key and should lock their door whenever they leave the room. Please note that the electronics are the sole responsibility of the camper, and any theft or loss of electronics such as cell phones, tablets, or laptops is not camp staff responsibility. Expectations of Campers While At Camp 1. Attend every class and program activity and arrive on time 2. Be an active participant in all lectures, labs, and discussions 3. Work together as a team 4. Positively participate in the activities 5. Communicate with instructors when further clarity and explanation on material is needed 6. Demonstrate respect for all classmates, faculty and instructors 7. Follow established classroom/activity expectations and policies 8. Respect classrooms, CSU campus, visited facilities and yourself at all times 9. Turn off cell phones and electronic devices during presentations and any scheduled activities 10. Learn, be present, be engaged and have fun! Health Awareness Altitude sickness is something that visitors to Colorado commonly experience, and it can affect a traveler's sense of well-being quite profoundly. In addition to making one feel dizzy or full of nausea, the lack of moisture in the air can cause your hair, skin and eyes to become uncomfortably dry, and may even cause nosebleeds. A feeling of breathlessness, especially when exercising, is also commonly reported. However, these symptoms may or may not be medically classified as altitude sickness, or AMS. The official diagnosis of AMS is made when a headache, with any one or more of the following symptoms is present after a recent ascent above 2500 meters (8000 feet): Loss of Appetite, nausea or vomiting Fatigue or weakness Dizziness or lightheadedness Difficulty sleeping Fort Collins is at a comfortable 5,003 ft, so this kind of reaction to altitude is extremely rare. However, if you feel any symptoms of altitude sickness during your stay on campus, please alert camp staff immediately. The weather in Colorado in July is typically very hot and dry, but can change very quickly with afternoon thunderstorms. Remind your student to drink plenty of water. They will probably walk up to 3 miles a day around campus during our daily activities so be sure they bring comfortable shoes and a refillable water bottle.

16 CSU is proud to be an environmentally responsible campus by using resources and nonwasteful ways of keeping our campus beautiful. Water used to sprinkle the grass on campus is untreated lake water, which means you should not drink it, or get it in your eyes, mouth, or open wounds. As tempting as it is on a hot summer day, please DO NOT run through sprinklers. Daily Schedule and Details of Activities: Sample Daily Schedule Resident Student: 6-6:45 a.m.: Wake Up/Get Dressed 7-7:50 a.m.: Breakfast at Ram s Horn 8-10 am: Curriculum in Lecture Hall am: Computer Lab Cross Sections 11 a.m p.m.: Lunch 12-2 p.m.: Cadaver Lab 2-4 p.m.: Hands on learning activities 4-5 p.m.: Break in dorms 5-6 p.m.: Dinner at Ram s Horn 6-7 p.m.: Extracurricular activities 7-9 p.m. Structured night activities led by counselors 9:00pm-10:30pm: Quiet time in dorms 10:30-11 p.m.: Lights out Lab Activities: Cadaver viewing, Clay Model Construction, Sheep Brain Dissection, Pig Heart Dissection, and Suture Clinic Extracurricular Activities: Whitewater Rafting: We will be using Wanderlust Whitewater Rafting Company ( ). This exciting and memorable adventure is perfect for those new to the sport of rafting or for those desiring a family trip. Campers will raft many fun and continuous rapids like Pinball, Rollercoaster, the Squeeze, Slideways and Headless Bridge! Kids love to ride in the front of the raft where they can get splashed while water fighting with other boats. During your trip we stop to play in our favorite swim hole. The crystal clear water is refreshing on a hot day and floating down through the waves will be the highlight of your whitewater experience! Difficulty : Class II,III (Beginner/Intermediate) Hike to Horsetooth Falls : Horsetooth Mountain Open Space Park encompasses the Culver, Soderberg, and Hughey Open Spaces. This 2,886 acre park is located on the west side of Horsetooth Reservoir, 4 miles west of Fort Collins and 12 miles northwest of Loveland.

17 Horsetooth Mountain Open Space Park supports 29 miles of multipurpose trails through native grasslands, ponderosa woodlands and montane forests. Horsetooth Falls Hike : Round-Trip Length: 2.35 miles (roundtrip to base of falls) Start-End Elevation: 5,815' - 5,830' (5,923' max elevation) Elevation Change: +15' net elevation gain (+425' total roundtrip elevation gain) Skill Level: Easy-Moderate Fort Collins Museum of Discovery ( ) The Fort Collins Museum of Discovery, featuring 16,000 square feet of permanent and changing gallery space, two fully outfitted classrooms, an expanded Local History Archive,and a digital dome theater. The museum provides hands-on explorations in science and technology and houses both historical and scientifically themed exhibits relevant to Fort Collins and the northern Colorado area. In 2005, Fort Collins voters passed a Building on Basics tax package, which approved and provided funding for the merger of the Fort Collins Museum and Discovery Science Center. Since then, the two institutions have been focused on planning, developing, and establishing a public-private partnership that will bring together these two cornerstone cultural organizations. At the core of the planning process is the museum's partnership promise: to deliver an exceptional visitor experience while fulfilling the mission of each museum. Designed with a seamless experience as the goal, visitors will explore and engage in exhibits and programs that unite science and culture in unique and thought-provoking ways. Student Recreation Center CSU's award-winning Student Recreation Center has had its share of national attention. The Rec, funded entirely by student fees, is a breath-taking combination of state-of-theart amenities and eye-popping architectural design. Several publications have listed the CSU Student Recreation Center to their "Best Of" lists, including Men s Health, Best Value Schools, and Best College Reviews. Housed within the Student Rec Center, the Aquatic facility features a rock wall, current channel, four 25-yard lap lanes, zero depth entry with sprayers, volleyball and basketball area, spa, sauna, and steam room.

18 FOR STUDENT 1. Attend every class and program activity and arrive on time 2. Be an active participant in all lectures, labs, and discussions 3. Work together as a team 4. Positively participate in the activities 5. Communicate with instructors when further clarity and explanation on material is needed 6. Demonstrate respect for all classmates, faculty and instructors 7. Follow established classroom/activity expectations and policies 8. Respect classrooms, CSU campus, visited facilities and yourself at all times 9. Turn off cell phones and electronic devices during presentations and any scheduled activities 10. Learn, be present, be engaged and have fun! Altitude sickness is something that visitors to Colorado commonly experience, and it can affect a traveler's sense of well-being quite profoundly. In addition to making one feel dizzy or full of nausea, the lack of moisture in the air can cause your hair, skin and eyes to become uncomfortably dry, and may even cause nosebleeds. A feeling of breathlessness, especially when exercising, is also commonly reported. However, these symptoms may or may not be medically classified as altitude sickness, or AMS. The official diagnosis of AMS is made when a headache, with any one or more of the following symptoms, is present after a recent ascent above 2500 meters (8000 feet): Loss of appetite, nausea, or vomiting Fatigue or weakness Dizziness or light-headedness Difficulty sleeping

19 Fort Collins is at a comfortable 5,003 ft, so this kind of reaction to altitude is extremely rare. However, if you feel any symptoms of altitude sickness during your stay on campus, please alert camp staff immediately. The weather in Colorado in July is typically very hot and dry, but can change very quickly with afternoon thunderstorms. Please plan to drink plenty of water. You will probably walk up to 3 miles a day around campus during our daily activities so please bring comfortable shoes and a refillable water bottle. CSU is proud to be an environmentally responsible campus by using resources and nonwasteful ways of keeping our campus beautiful. Water used to sprinkle the grass on campus is untreated lake water, which means you should not drink it, or get it in your eyes, mouth, or open wounds. As tempting as it is on a hot summer day, please DO NOT run through sprinklers. Toiletries: Toothpaste and toothbrush Deodorant Hairbrush/ comb Shampoo/conditioner Soap (with case) Bug spray/ Insect repellent Sunscreen Chap stick Extra blanket or sleeping bag (sheets, pillows and a blanket are provided) Clothing: Casual summer clothes (please keep it school appropriate) Clothes you are comfortable hiking in Fleece Jacket and long pants or jeans (nights are cool in Colorado) Rain jacket (Colorado is known to have rainy summers) Athletic wear for an evening in the rec center and team building activities outside Required for rafting : shoes that can get wet but are secured to your feet (no flip flops or crocs) and quick dry shirt/ shorts

20 Required for Cadaver lab : old pair of clothes to wear in lab under scrubs (Scrubs provided at camp); closed toed shoes (no flip flops or backless shoes); elastic hair band to keep hair pulled back Recreation Equipment: Swim suit Swim towel Frisbee, hacky-sac, football, etc. Miscellaneous Items: Journal (Will be used for daily assignments and reflections) Small games for dorm (cards, uno, mad-libs, etc.) Extra pair of glasses or contacts Croakies Sunglasses Shower robe Personal Electronics (Please note: Camp staff not responsible for lost or stolen items) All items on this list are highly recommended but may not be all inclusive. Please use your personal discretion to bring any other items necessary for your week at camp.

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