Huntington University Nursing Career Academy Application Process Summer 2015

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1 Application Process Eligibility Requirements: applicants must be in 10 th, 11 th, or 12 th grade during the academic school year and be interested in exploring a career in nursing. Program cost: $299 if registered by March 1, 2015 or $350 after March 1, 2015 Program s: July 13, 2015 July 17, 2015 Selection Criteria: Selection will be based on eligibility and a first come first serve basis. Application Procedure: 1. The application deadline is June 30, Registration cannot be confirmed until payment is received in the mail or credit card information is processed. 3. Registration fees are non-refundable after the application deadline. 4. The complete application package must be sent together or completed online and include: Completed Application Medical Release Form Release Forms Code of Conduct Form Payment 5. The application may be completed online or mailed to: Huntington University Department of Nursing 2303 College Avenue Huntington, IN Questions: For any questions about the program or application process, please feel free to call the Huntington University Nursing Department at or the camp director at

2 Application Please use ink or type application Name: Goes by: First Middle Last Gender (Please circle): Male Female of Birth: Age: Grade in the Fall: Street Address: City: State: Zip: Home Phone: ( ) Parent/Guardian s Name(s): Parent Parent Phone: ( ) Parent Work Phone: ( ) Emergency Contact (other than parent or guardian): Name: Relationship: Phone: ( ) Name of School: School Address: City: State: Zip: School Phone: ( ) School Fax: ( ) Teacher/Guidance Counselor Name: Phone Number: ( ) Special Dietary Needs or restrictions: Shirt Size: XS S M L XL 2XL 3XL Have you ever taken CPR? if so, when? Have you ever taken a First Aide Class? if so, when? How did you hear about the camp? Selection Criteria: Selection will be based on a first come first serve basis

3 Medical Release Form Student Name: Gender: Male / Female of Birth: / / Grade in School: Parent(s)/Guardian(s) Name: Street Address: City/State/Zip: Home Phone: Cell Phone: Medical Insurance Company: Group I.D/Policy Number: Allergies (any including foods, medications, latex, insect bites, etc) : Please describe the reaction and what is done to manage above allergies: Any anaphylaxis? Yes / No Medications: Please list any medications the student will need to take during the camp: including medication name and time taken: Huntington University has permission to administer Tylenol, Motrin, or Benadryl to my child if the need arises: Yes / No of last Tetanus Shot: Any factors or chronic concerns which might affect the student s participation in the Huntington University Nursing Career Academy? Any activity restrictions? Any special housing needs? If parent/guardian is unavailable in case of an emergency, please contact: Name: Relationship: Phone: The medical history listed above is complete and correct to the best of my knowledge. I approve of this students participation in this event and certify that he/she is in good health and able to participate in all activities. I hereby voluntarily assume all risk of accident or injury to my child which may arise from his/her participation in this event, completely releasing Huntington University and all personnel associated with this program from any liability that may result from his/her participation. If medical attention is required for illness or injury while attending this event, I give my permission for such care.

4 Release Form Student Name: Name of Parent(s)/Guardian(s): Photo Release: I hereby grant Huntington University permission to take and use my (or my student s) image in University marketing promotions such as, but not limited to, websites, videos, printed materials and press releases. I understand my (or my student s) image will be used in a tasteful, professional manner. I agree that images used are considered the property of Huntington University and may not be sold or reused without the express consent of Huntington University. Liability Waiver: Though Huntington University makes every effort to ensure the safety, protections and supervision of students attending a Huntington University summer program, participants must abide by University rules and regulations. Huntington University will not accept responsibility for actions or injuries to or by students incurred while violating University rules and regulations, or local, state or federal laws. The parent or guardian s signature below indicates acceptance of the above conditions and approval for his/her child to attend the Huntington University Nursing Career Academy. It also signifies that the parent or guardian is aware that off campus activities are planned throughout the week and the student has permission to travel in university vehicles to these events. Signature of Parent(s)/Guardian(s)

5 Release Form Student Name: Name of Parent(s)/Guardian(s): Permission to Leave Campus: We take our responsibility for enrolled students very seriously. We foresee no reason for any student to leave campus without the supervision of a staff member. If, however, there is a specific reason (such as visiting a relative) for the student to leave campus, please indicate below. We cannot honor blanket permissions. I give permission for to leave campus at the following specific times, for the following reasons, and to visit the listed places. Destination Purpose Time Depart Time Return Vehicle Information: If you plan on bringing your own vehicle, we need to know. We must insist that students not use their cars during the duration of the camp. Failure to comply with this rule will be considered a serious breach of the camps rules and may be grounds for the student being asked to leave the camp. No, I will not be bringing a vehicle with me to the camp. Yes, I will be bringing a vehicle with me to the camp. The car I am bringing is: Make: Model: Year: State: License Plate #:

6 Code of Conduct Student Name: I will be respectful of all individuals (other students, adults, non-academy staff working on campus) while at the Huntington University Nursing Career Academy. This includes observing the evening curfew and being on time for all sessions and activities. I will not use my cell phone during camp activities and sessions. I will be respectful of all public and private property, including college dorms, classroom spaces and Parkview Hospitals. I will not use alcoholic beverages, tobacco products, or illicit drugs of any kind while at the Nursing Career Academy and Huntington University. I will not use drugs unless prescribed by a licensed physician and these have been listed on the medical form I will be including in my registration. I will keep my counselor informed of my whereabouts and will not leave the classroom or dorms without faculty or staff permission and supervision. I will wear my identification badge at all times and keep my dorm room key with my badge. I understand if I lose my dorm key, I will be responsible for paying to replace the key (approximately $30 per key). I understand that I could be sent home if in violation of any of the rules above and that being sent home will be at my parent/guardian s expense. Student Signature: Parent/Guardian Signature: Parent/Guardian Information (all fields required) First and Last Name(s): Street Address: City/State/Zip: Home Phone: Cell Phone: Parent/Guardian Address:

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