Healthcare Career Day Camp for High school students Augsburg College July 10-14, 2017 REGISTRATION FORM (Please make sure all pages are completed and signed) Metro Scrubs Camp will take place from Monday, July 10 th through Friday, July 14 th on the Augsburg College campus. The camp begins at 8:00 am and ends at 5:00 pm each day. The cost of Urban Scrubs Camp is $430 (this includes a $30 non-refundable processing fee). Some scholarships are available. Instructions You may pay in full NOW or send in the $30 non-refundable processing fee to secure your spot. The balance will be due on or before May 30, 2017. You will receive an email regarding your balance. Checks or money orders should be made payable to Augsburg College Metro Scrubs Camp. Credit Cards are accepted for online registration. Scholarships of $400 are available on a limited basis. Please complete the Scholarship Section Form to apply for a scholarship. Fill out all information requested on pages 1-4 (please type or print legibly). Send the completed Registration Form (with Scholarship Section, if applicable) and the $30 processing fee made payable to Augsburg College-Metro Scrubs Camp to: Hli Vang Metro Scrubs Camp 2211 Riverside Dr. Minneapolis, MN 55454 For more information: Phone: 612-359-6486 Email: scrubscamp@augsburg.edu Student Information (All fields are required) Have you attended Scrubs Camp before? Yes No Will you be applying for a scholarship? Yes No If yes, complete the scholarship section First name Middle name Last name Home address City State Zip Parent name Parent home phone Parent cell phone Emergency contact name Emergency phone Student email & Student Phone Parent/guardian email Sponsored by HealthForce Minnesota and Augsburg College Page 1 of 6
Circle Current Grade (2016-2017): 8 th 9 th 10 th 11 th 12 th Circle Gender: Male Female Date of Birth: Circle Scrubs Size: ExSm. Sm. Med. Lg. XLg. Diet or health concerns: Ethnic Background (this information helps establish scholarship opportunities for future camps) American Indian/Alaskan Native Asian/Asian American Black/African American Hispanic/Latino/Spanish Native Hawaiian/Other Pacific Island White/Caucasian Mixed Other Sponsored by HealthForce Minnesota and Augsburg College Page 2 of 6
Scholarship Section (complete to apply for scholarship) Scholarships are available on a limited basis to students with financial need. Students applying for a scholarship will be required to pay $30 registration fee. If student is not awarded a scholarship, the $30 will be refunded. Student first & last name: Name of School School city: Counselor Name Counselor phone: Counselor Email Does student qualify for free/reduced lunches? Yes No NOTE: If you do not know the information below, we will request it from your school counselor. Student grade point average in sciences Student grade point average overall Student MARSS number (10 digits) Student birthdate Tell us in one paragraph what you hope to gain by attending Scrubs Camp. I give my permission for the school to provide the information above regarding my child. I also give permission for us to contact the counselor or teacher given as a reference to answer the questions. Parent/Guardian Signature: Printed Name: Sponsored by HealthForce Minnesota and Augsburg College Page 3 of 6
Behavior Policy I will be respectful of all individuals (other students and adults) while at Metro Scrubs Camp. This includes being on time for all Camp sessions and activities. I will not use my cell phone during sessions at Camp. I will be respectful of all public and private property, including Augsburg College classroom spaces and other facilities. I will not use alcoholic beverages, tobacco products, or illicit drugs of any kind while at Camp. I will not use drugs unless prescribed by a licensed physician, in which case a medication form needs to be completed at check-in. Medications must be administered by Camp staff. I will keep my Camp counselor informed of my whereabouts and will not leave the Augsburg College campus without the supervision of Camp staff. If I drive myself to Camp, I will turn in my car keys each day for safety and liability reasons. I will wear my Camp identification badge and/or my scrubs top at all times. I understand that I will be sent home if I am in violation of any of the rules above. Student Signature: Parent/Guardian Signature: Please Note: Registration form, behavior waiver, liability waiver and photo waiver MUST be completed and signed for student to participate. ------------------------ Photo Waiver ------------------------- I consent to allow Augsburg College and/or HealthForce Minnesota ( The Sponsors ) to photograph me and/or my minor child listed below. The Sponsors may produce publications and/or promotional materials which may involve the use of my and/or my minor child likenesses. Such publications will be used for noncommercial educational, exhibition, promotional, advertising, or other purposes by the Sponsors and will not be sold to other entities and/or agencies. Such materials may be copied, copyrighted, edited, and distributed by the Sponsors. I understand that my and/or my child likeness/image may be used in the manner described above, and grant the Sponsors the right to use and reuse, in any manner at all, the still photograph productions and/or publications as described above. I hereby forever release and discharge the Sponsors from any and all claims, actions and demands arising out of or in connection with the use of said still photograph, including without limitation, any and all claims for invasion of privacy and libel. This release shall inure to the benefits of the assigns, licensees and legal representatives of the Sponsors as well as the party(ies) for whom the sponsors took the still photograph. I represent that I have read the foregoing and fully and completely understand the contents hereof. Parent/Guardian Signature: Printed Name: Date Please Note: Registration form, behavior waiver, liability waiver and photo waiver MUST be completed and signed for student to participate. Sponsored by HealthForce Minnesota and Augsburg College Page 4 of 6
Liability Waiver I have agreed to allow my child to participate in the Metro Scrubs Camp. I understand that as part of the Camp, my child may have the opportunity to participate in various other activities such as hiking and other outdoor activities. I am aware of the dangers and risks to person and property that may be caused while participating in these activities. Risks associated with participation in these activities include, but are not limited to, loss of or damage to personal property, bodily injury, or even death. All such risks are known, understood, and assumed by me. In consideration of Augsburg College and HealthForce Minnesota ( The Sponsors ), I permit my child to participate in these activities, I agree as follows: 1) I represent and warrant that my child is covered by a policy of comprehensive health and accident insurance which provides coverage for illnesses or injuries my child may sustain or experience, and provides coverage for emergency medical evacuation and for repatriation of remains. By my signature below, I certify that I have confirmed that my health insurance policy will adequately cover my child; and, I hereby release and discharge the Sponsors of all responsibility and liability for any injuries, illnesses, medical bills, charges or similar expenses, emergency evacuation expenses, and repatriation related expenses that my child incurs while participating in the Camp. 2) I, individually, and on behalf of my heirs, successors, assigns and personal representatives, hereby release and forever discharge the Sponsors and its employees, agents, officers, trustees and representatives (in their official and individual capacities) ( Releasees ) from any and all liability whatsoever for any and all damages, losses or injuries (including death) my child sustains to person or property or both, including but not limited to any claims, demands, actions, causes of action, judgments, damages, expenses and costs, including attorney fees, which arise out of, result from, occur during, or are connected in any manner with my child s participation in the trip and/or any travel incident thereto, whether caused by the negligence of the Releasees or otherwise; except that which is the result of gross negligence and/or wanton misconduct by the Releasees. 3) I, individually, and on behalf of my heirs, successors, assigns and personal representatives, hereby agree to indemnify, defend and hold harmless the sponsors and its employees, agents, officers, trustees and representatives (in their official and individual capacities) from any and all liability, loss, damage or expense, including attorney fees, that they or any of them incur or sustain as a result of any claims, demands, actions, causes of action, damages, judgments, costs or expenses, including attorney s fees, which arise out of, occur during, or are in any way connected with my child s participation in the Camp. 4) I agree that this Waiver, Release and Indemnification Agreement is to be construed under the laws of the State of Minnesota, U.S.A.; and that if any portion thereof is held invalid, the balance hereof shall, notwithstanding, continue in full legal force and effect. In signing this document, I hereby acknowledge that I have read this entire document, that I understand its terms, that I am the parent or legal guardian of the minor child listed above and that by signing it am giving up substantial legal rights I might otherwise have, and that I have signed it knowingly and voluntarily. Parent/Guardian Signature: Name (Printed) Date Sponsored by HealthForce Minnesota and Augsburg College Page 5 of 6
KEEP THIS PAGE FOR IMPORTANT INFO!!! Registration checklist: 1) Read and complete all pages legibly. 2) All highlighted areas must be signed. 3) Make sure to give us an email address; this is how we prefer to communicate with you. Our email address is scrubscamp@augsburg.edu 5) Mail registration forms and payment to: Hli Vang Metro Scrubs Camp 2211 Riverside Dr. Minneapolis, MN 55454 You can mail your full payment NOW or send us the $30 non-refundable processing fee to hold your spot. Cost of camp: $430 (includes the $30 non-refundable processing fee) The balance will be due May 30, 2017; you will receive an email reminder. Checks should be payable to Augsburg College Metro Scrubs Camp. Scholarships in the amount of $400 are available on a limited basis for first time applicants. To apply for a scholarship, complete the Scholarship Section. The processing fee will be reimbursed if you are not awarded a scholarship and do not attend camp. Questions? Call 612-359-6486 or scrubscamp@augsburg.edu Sponsored by HealthForce Minnesota and Augsburg College Sponsored by HealthForce Minnesota and Augsburg College Page 6 of 6