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2024 Camp Registration Form

Coding Camp will be held on Maryville University’s campus for Grades 6th -8th from July 10-14, 2023 or Grades 9th-12th from July 17-21, 2023. Transportation will be provided by your student’s school district. All participants should be registered BEFORE May 15, 2023. 
If you need assistance or have questions, please contact Gretchen at stem@maryville.edu.

Attendance Choice(s)

Coding Camp Week

Robotics Camp Week

Select the dates your camper will attend Distance Running Camp.

June 8June 11June 15June 18June 22June 25June 29(Each selected date is a $20 charge.)

Attendee Information

Participant First Name:

Participant Last Name:

Participant Date of Birth:

Email:

Participant Phone:

Participant Mailing Address:

Street, City, State, ZIP

Participant School District:

Other District:

Are you affiliated with Vitendo4Africa?

YesNo

Participant School:

Prior Year(s) Participated

2017	2018	2019
2020	2021	2022
2023	None

Participant's Grade for 2023/24 School Year

Participant's Gender

MaleFemaleOther

Participant Ethnicity:

Residency Option:

Pricing Information

Please indicate the names of your preferred roommates.

There will be 2 to 4 campers per room assignment. Your request is not guaranteed but we will do our best to accommodate.

Participant T-Shirt Size:

T-Shirt Size:

Parent/Guardian Information

Parent/Guardian 1 Full Name:

Parent/Guardian 1 Phone:

Parent/Guardian 1 Email:

Parent/Guardian 2 Full Name:

Parent/Guardian 2 Phone:

Parent/Guardian 2 Email:

Which phone numbers provided are OK to text program reminders?:

ParticipantParent/Guardian 1Parent/Guardian 2None

Emergency Contact Name (to be notified if parents/guardians are unavailable):

Emergency Contact Relationship:

Emergency Contact Number:

Safe Pick Up List

Safe Pick contacts must show a photo ID at pick up with a first and last name that matches what is entered here.

Attendee's Medical Contacts

Physician's Name:

Physician's Number:

Dentist's Name:

Dentist's Number:

Specialist's Name:

Specialist's Number:

YesNo

Minor Program and Activities Medical Form Health History, Immunizations, Permission for Emergency Treatment

Part I - Health History

Please check any of the following that apply and note next to each the diagnosis and date when the condition started.

1. Allergies/Adverse reaction to medications/food/insects/other?

NoYes

Please specify.

2. Does the minor take any medications on a frequent or regular basis?

NoYes

Please list ALL prescription AND nonprescription medications AND supplements. Please include dosage and frequency.

3. Has the minor ever had any health problems, surgeries, operations, or hospitalizations?

Medical Condition/Concern

Diagnosis/Date Diagnosed (If Yes)

Appendectomy

NoYes

Asthma

NoYes

ADD/ADHD

NoYes

Chicken Pox/Varicella

NoYes

Depression/Anxiety (specify)

NoYes

Diabetes Mellitus

NoYes

Eating Disorder/Anorexia/Bulimia

NoYes

Emotional/Psychological Problem

NoYes

Orthopedic Impairment

NoYes

Vision Impairment

NoYes

Learning/Intellectual Disability

NoYes

Epilepsy/Seizure Disorder

NoYes

Heart Condition/Disease/Murmur

NoYes

HIV or AIDS

NoYes

Migraine Headaches

NoYes

Mononucleosis/Epstein-Barr Virus

NoYes

Splenectomy

NoYes

Tonsillectomy

NoYes

Viral Hepatitis (specify A, B, C)

NoYes

Sickle Cell Disease/Trait

NoYes

Hearing Impairment

NoYes

Kidney/Urinary Conditions

NoYes

Other Health Condition not previously listed:

Please note: If your child has health condition requiring emergency medication (I.e. asthma, allergies, diabetes, seizures, etc.) please attach a Health Action Plan provided by your health care provider.

Part II - Special Considerations

1. Does this minor have a disability or health impairment that could affect their participation in the camp, program or activity?

NoYes

*Maryville University will consider requests for accommodations on an individualized basic. Please note that this evaluation may differ from your child's experience in a K-12 academic setting and that the Individuals with Disabilities Education Act does not apply. Please consult Maryville's Minors Accessibility Policy for more information.

2. If so, what documentation can you provide to explain the disability or other health impairment and the accommodations your child may require to be successful in the camp, program or activity? (e.g., medical documentation, individualized education plan (IEP) or 504 plan)?

For individuals participating in a residential program, are there any concerns which could affect this minor's ability to live at ease with a roommate? This could include, but is not limited to mood disorders, transgender, extreme sleepwalking/talking, bedwetting, chronic cough/snoring, sleep disturbances, severe allergies, etc.)?

Part III - Immunization

Immunization against infectious diseajeprotect the individual against personal infection and reduces the risk of contagious disease for all PROGRAM participants. The University strongly recommends parents ensure that their child's immunizations are up to date with current CDC recommendations.

The following vaccinations (which most children in the United States should have had as part of their regular vaccinations during childhood) are recommended:

Measles, Mumps, and Rubella vaccine (MMR)
Diptheria/Tetanus/Pertussis vaccine (DPT, DTAP)
Varicella (chickenpox) vaccine
Polio vaccine (IPV)
Hepatitis B vaccine series
For students entering Grade 8 or higher: Meningococcal conjugate vaccine (MCV4) and TDAP

There are numerous childhood vaccinations, each given a schedule. The best way to determine if your child's immunizations are up to date with current recommendations is to speak with your child's health care provider or your county health department.

If there is any reason to suspect that your child has been exposed to tuberculosis (TB), he or she should be tested, either by a skin test or a blood test. This testing can be done through your health care provider's office or county health department.

My child has completed the following vaccinations: (please check the appropriate box)

1. Measles:

YesNoUnknown

2. Mumps:

YesNoUnknown

3. Rubella:

YesNoUnknown

4.Diphtheria/Tetanus/Pertussis (DTAP):

YesNoUnknown

5. Varicella (Chicken Pox):

YesNoUnknown

6. Polio:

YesNoUnknown

7. Hepatitis B:

YesNoUnknown

Entering Grade 8 or higher only:

8. Meningitis conjugate (MCV4)

YesNoUnknown

9. TDAP:

YesNoUnknown

Part IV - Optional Insurance Information

In the event of a medical emergency, it is often helpful for the Program to have a minor's medical insurance information to give to the healthcare provider. Providing this information to the Program is optional.

Insurance Provider:

Policy ID:

Group ID:

Name of Policy Holder:

Relation of Minor to Holder :

Part V - Permission for Emergency Treatment

Program Consent/Permission for Emergency Medical Treatment and Sharing of Medical Information

As the parent/guardian of my minor (under 18 years of age) son or daughter,

I hereby authorize:

1)       The sharing/exchange of relevant medical information between program representatives (officials, faculty, dormitory staff), other Maryville University (“the University”) representatives (faculty, staff, employees), and, for the purpose of diagnosis and/or treatment, other medical providers.  Each of the above individuals or entities is also authorized to communicate and discuss with the parents/guardians/emergency contacts of my minor child health, academic, administrative or disciplinary matters related to his/her enrollment in the summer program.

2)       The transportation of my minor child, in either a private or university vehicle, by program/activity staff, to on-campus or off-campus medical care should such be required.

3)       The provision, by physician or healthcare professional, of such diagnostic, therapeutic, voluntary immunization, and operative procedures and transportation as may be deemed necessary for my minor son/daughter.

Any and all related expenses will be the responsibility of the minor and/or parent/guardian.  I further understand that under certain appropriate circumstances my son/daughter will be transported to area hospitals for diagnosis and/or treatment.  I understand that program representatives will make reasonable efforts to contact and inform me or another parent/guardian/emergency contact before performing non-routine diagnostic/treatment procedures except in an emergency.

Minor's Signature:

Minor Signature Date:

PARENT'S OR GUARDIAN'S WAIVER

(Must be completed by all parents and guardians for participants under the age of 18)

Parent or Guardian Signature 1:

Parent/Guardian 1 Signature Date:

Parent or Guardian Signature 2:

Parent/Guardian 2 Signature Date:

Any signature (including any electronic symbol or process which indicates an intent to sign or authenticate this form) shall have the same legal validity and enforceability as a manually executed signature on a paper-based record to the fullest extent permitted by applicable law, including the Federal Electronic Signatures in Global and National Commerce Act, Missouri Revised Statute Section 432.230, or any similar state law based on the Uniform Electronic Transactions Act.

ASSUMPTION OF RISK FORM REGARDING COMMUNICABLE DISEASE TRANSMISSION

In consideration of the services provided by Maryville University, its board, employees, volunteers, participants, and all other persons or entities acting in any capacity on its behalf (collectively referred to as “UNIVERSITY”) in conjunction with the (“Event”) named below:

I hereby agree as follows:

1. I acknowledge that participation in the Event entails known and unanticipated risks related to communicable disease, including, but not limited to, COVID-19, meningitis, tuberculosis, and health consequences due to such exposure or infection. I understand that these risks cannot be eliminated. I also understand that I cannot be guaranteed that I will not contract a communicable disease while participating in the Event.

2. I understand that the Event involves

small group and large group activities, shared meals in University dining locations

actividades en grupos pequeños y grandes, comidas compartidas en el comedor del universitario.

I further understand that the risks associated with communicable disease transmission may vary based on the following risks inherent to the Event:

activities held indoors, personal proximity to Event staff, personal proximity to Event participants, personal proximity to other persons present at the Event’s location, shared meals, adherence to social distancing practices, and travel.

actividades realizadas en el interior, proximidad con el personal del evento, proximidad personal con otras personas presentes en el lugar del evento, comidas compartidas, adherencia a las prácticas de distanciamiento social y viajes.

3. I understand that participants may not be required to wear face coverings or maintain social distances unless required by local or state laws.

4. I understand that if I am exposed to or infected by a communicable disease, I may be required to leave the Event immediately.

5. I expressly agree and promise to accept and assume the communicable disease transmission risks existing with participating in the Event. My decision to participate in the Event is purely voluntary, and I elect to participate despite the risks. I further certify that I am willing to assume the risk of any medical or physical condition I may have.

By signing this document, I expressly state that I have had sufficient opportunity to read this entire Agreement.

I further certify that I have read and understood it, and I agree to be bound by its terms.

Participant's Agreement

Participant Full Name

Today's Date

Participant Date of Birth

Participant Phone

Participant Address

Parents'/Guardians' Waiver

This section must be completed by all parents and guardians for participants under the age of 18.

In consideration of:

Minor's Full Name

(“Minor”) being permitted to participate in the Event, I agree that my child’s participation in the Event is to be bound by the terms of this Agreement and further agree to waive any and all claims of negligence against UNIVERSITY which are brought by, or on behalf of Minor, and which are in any way connected with the Event, including transportation to and from the Event.

Parent/Guardian 1 Full Name

Date

Parent/Guardian 2 Full Name

Date

EPI-Pen Form & Release

Does the participant require the use of an EPI-Pen?

YesNo

If you provide an Epi-Pen for your child we will permit our staff to receive and administer the Epi-Pen if you agree to the following terms and sign this agreement. The agreement must be returned to the Program Administrator prior to the student’s first day at the program. Please note that we will only accept an Epi-Pen that is in its original container with the appropriate label intact.

Student Information

Participant Full Name

Participant Date of Birth

Emergency Contact Information

Emergency Contact Full Name

Emergency Contact Relationship

Emergency Contact Phone Number

EPI-Pen Information

Type of EPI-Pen

Regular EPI-PenEPI-Pen Jr.

To what is your child Allergic (specify which foods, insections, etc.)?

For food items, to date is the allergy only if the food is ingested? If not, please explain:

Describe the type of allergic reaction, including signs and symptoms if your child is in distress:

Please attach a Health Action Plan provided by your health care provider and/or instructions for the administration of the Epi-pen

PERMISSION TO ADMINISTER EPI-PEN & RELEASE AND WAIVER OF LIABILITY AGREEMENT

I (we) give continuing permission to Maryville University ("the University")'s program, and program staff to administer the Epi-Pen to our child in the event that , in such staff member's judgement, our child is in need of an injection.
I (we) hereby release, waive discharge and covenant not to sue the University, its board, officers, agents or employees and its program (hereinafter referred to as "releases") from any and all liability, claims, demands, actions and causes of action whatsoever arising out of or relating to any loss, damage or injury, including death, arising out of or in connection with the decision to administer the Epi-Pen to our child, the administration of the Epi-Pen to our child, or the decision not to administer the Epi-Pen to our child , barring the releasees' intentional misconduct.
I (we) agree to defend, indemnify and hold harmless the releasees of and against any and all liability, damage, claim, demand, cost and expense (including, without limitation, reasonable attorney’s fees) arising out of or in connection with the decision to administer the Epi-Pen to our child, the administration of the Epi-Pen to our child, or the decision not to administer the Epi-Pen to our child, barring the releasees’ intentional misconduct.
It is my express intent that this Release shall bind the members of my family and spouse, if I am alive, and my heirs, assigns and personal representative, if I am deceased, and shall be deemed as a Release, Waiver, Discharge and Covenant Not to Sue the above named releasees.

Minor's Signature:

Minor Signature Date:

PARENT'S OR GUARDIAN'S WAIVER

(Must be completed by all parents and guardians for participants under the age of 18)

Parent or Guardian Signature 1:

Parent/Guardian 1 Signature Date:

Parent or Guardian Signature 2:

Parent/Guardian 2 Signature Date::

Minors Program or Activity Media, Photo and Video Release Form

Program Information

Program/Activity Name

Start Date

End Date

Participant Information

Minor's Full Name

Date

PLEASE READ THIS DOCUMENT CAREFULLY BEFORE SIGNING. THIS IS A LEGALLY BINDING DOCUMENT.

In consideration for my child’s participation in the above captioned event, I, the undersigned parents/guardians of the minor child indicated below, hereby grant to Maryville University, its Board of Trustees, Administration, Faculty, Staff, and all other officers, directors, employees and agents (“the University”) the right to reproduce, use, exhibit, display, broadcast, distribute, modify, adapt, and create derivative works of photographs, videotaped images or video/audio recordings of my child (“Materials”) by incorporating them into publications, catalogues, brochures, books, magazines, photo exhibits, motion picture films, videos, electronic media, web sites, and/or other media, or commercial, informational, educational, advertising, or promotional materials or publications related thereto (“Works”). It is agreed that the Works will be used in connection with University business, the activities of the University, or for promoting, publicizing or explaining University activities or events.
Materials may appear in any of the wide variety of formats and media now available to the University and that may be available in the future, including but not limited to print, broadcast, videotape, CD-ROM and electronic/online media.
I waive my right to inspect or approve any Works that may be created by the University using the Materials and waive any claim with respect to the eventual use to which Materials may be applied.
I understand and agree that the University is and shall be the exclusive owner of all right, title, and interest, including copyright, in the Works, and any commercial, informational, educational, advertising, or promotional materials containing the Materials. All electronic or non-electronic negatives, positives, and prints are owned by the University. I also understand that neither I nor my child will receive compensation in connection with the use of my child's image.
I understand that the terms of this RELEASE are contractual and not a mere recital. The information I have provided is disclosed accurately and truthfully. I acknowledge that I am signing this document freely and voluntarily. My signature on this document is intended to bind not only myself but also my successors, heirs, representatives, administrators, and assigns.

Do you consent to the photo and video release authorized above?

YesNo

PARENT'S OR GUARDIAN'S WAIVER

(Must be completed by all parents and guardians for participants under the age of 18)

Parent or Guardian Signature 1:

Parent/Guardian 1 Signature Date:

Parent or Guardian Signature 2:

Parent/Guardian 2 Signature Date::

DISCIPLINARY PROCEDURES AND CODE OF CONDUCT FOR YOUTH PROGRAMS AND CAMPS

University policies establish the standards and expectations for camp/program-participant behavior and reflect the University’s commitment to fostering character development and integrity. Violations of the Code of Conduct or camp/program rules, or failure to abide by reasonable directions by camp/program staff, will be addressed in the following manner:

A participant typically receives a warning from his/her camp/program staff member following a first-time offense.
After a severe offense or multiple rule infractions, the participant meets with the appropriate staff members, including the applicable camp/program administrator. The administrator assigns appropriate and reasonable consequences at her/his discretion, and her/his decision is final. Parents are contacted by the administrator and informed about the incident and consequences.
In cases where a participant commits a violation that may subject him/her to dismissal from the program, the participant and parent(s)/guardian(s) are notified of the alleged violation before a decision is made. The administrator, Dean of Students, and Director of Residential Life, or their desginees (hereinafter, “Disciplinary Review Board” or “DRB”) will investigate the incident using their discretion. As part of that investigation, the DRB will give the accused participant an opportunity to present her/his point of view. Family members do not participate in an investigation or deliberations of the DRB. Decisions are made by consensus and at the discretion of the DRB, and such decisions are final. Following the decision, the participant and parent(s)/guardian(s) will be notified.

If a participant is dismissed from the program for disciplinary reasons, refunds will not be given.

Health or Safety Removal

Camp/program administrators may immediately remove minors from any camp, program and activity due to concerns that a minor’s behavior may pose a threat to the health or safety of themselves, other minors, or staff.

Future Camp/ Program Participation

A participant with multiple offenses and/or a severely egregious offense may be refused admission to subsequent camps and programs. Some participants may be allowed to return only after agreeing to certain conditions regarding their behavior and/or performance and demonstrated growth and maturity. In the event that a participant is dismissed, dismissal information may be provided to the University’s undergraduate admissions offices.

Code Of Conduct For Minor Participants

The following are prohibited under the University’s Minors Camps/Programs Code of Conduct

a. Drugs/Alcohol. The possession or use of unauthorized alcohol or drugs is prohibited. Possession is defined to include anyone who has actual physical contact of any kind with these substances OR is found to be knowledgeable of the possession of these substances by others and does not immediately remove himself or herself from the situation and inform a camp/program staff member.

b. Tobacco/ Vaping. Use of tobacco products or vaping products will not be tolerated by participants.

c. Hazardous Items. Fireworks, firearms, guns, knives, archery equipment and other weapons are prohibited unless being used for an officially sanctioned and approved instructional camp/program.

d. Vehicles. The operation of motor vehicles by minors is prohibited while attending and participating in the program (this excludes minors lawfully driving themselves to/from a camp/program).

e. Coming and Going. Rules and procedures governing when and under what circumstances participants may leave University property during the program, including sign-in / sign-out procedures.

f. Violence/Harassment. No violence, sexual abuse, or harassment will be tolerated. Physical, written or verbal abuse of any person, including self, or any action that threatens or endangers the emotional well-being, health or safety of any person, is unacceptable.

g. Hazing. Hazing of any kind is prohibited. Bullying including verbal, physical, and cyber bullying are prohibited.

h. Property. Misuse, tampering, vandalism, theft, damage or unauthorized access of University property or the property of others is prohibited. Charges will be assessed against those participants who are responsible for damaging or misusing University property.

i. Technology. The inappropriate or harmful use of smart devices, computers, internet, cell phones, cameras, imaging, and digital devices is prohibited including use of such devices in showers, restrooms, or other areas where privacy is expected by participants.

j. Identification. Participants known to be in possession of fake identification, including identification that misrepresents their name or age, will be dismissed from the program.

k. Behavior. Bullying, horseplay, gambling, pranks, practical jokes with malicious intent, violating the right of others, rudeness/ridicule of others (including, but not limited to, camp/program staff members, dining hall staff, housekeeping staff and other participants, etc.), is prohibited.

l. Sexual Contact/Activity. Engaging in sexual contact, activity, or conduct of any kind (does not include consensual hugging and kissing).

m. Dishonesty. Dishonesty is prohibited.

n. Violations. Any violations of federal, state or local laws, or University policies.

Please initial here that you have read and agree to the above.

Minors Programs and Activities Prescription and Non-Prescription Medication Requirements and Release for Nurse Administration

Absent an acute medical emergency, all medication for participants in this program must be administered by the program nurse. The program nurse will only administer medication properly delivered to the program and for which the participant’s parent or legal guardian has given proper written authorization.

All prescription medications, including medications for conditions such as food, drug or insect allergies, diabetes, asthma, or epilepsy, as well as non-prescription medications, such as Aspirin, Tylenol, Advil, Midol, Motrin, Sudafed and cold and allergy medication must be immediately brought to the program for controlled and secured storage by the program nurse or an adult camp/program staff. The only exceptions to this rule are for authorized inhalers and epi-pens which may be kept on the participants’ person.

Prescription medication must be in its original container labeled by the pharmacist or prescriber. Label must include the participant’s name, contents and dosage instructions written in English. Label must also include the name, address and phone number for pharmacist or prescriber. Non-prescription medication must also be in its original packaging.

The program nurse is the only staff member authorized to assist and remind participants in taking their prescription or non-prescription medications. Program/activity staff do not assist participants in taking their medication, nor do they remind participants to do so.

This form must be signed by a parent/legal guardian.

Program Information

Program/Activity Name

Start Date

End Date

Participant Information

Participant Full Name

Participant Date of Birth

Prescription Medications

Please indicate below whether your child will need to take prescription medications during the program:

NoYes

Please list ALL prescription medications, dosing instructions, and any storage requirements for each medication.

Non-Prescription Medications (known and unforeseeable need)

In the event it is known that a participant will require delivery of non-prescription medication over the course of the camp/program, a parent/legal guardian must provide a signed, written authorization or note including:
The participant’s name
The non-prescription medication
Dosing instructions
Acknowledgment of no known allergies of the participant to the medication
Assurance that the participant has been instructed by the parent or legal guardian in self-medication.

In the event of minor injuries or ailments participants may incur during the program, the program nurse may provide the following over-the-counter medications (or their generic equivalents) for the symptoms indicated after checking this form and attempting to contact a participant’s parent or legal guardian.

Please check all OTC medications that the program nurse MAY provide to your participant on an as-needed basis:

Acetaminophen for pain or headacheIbuprofen for pain, headache, or menstrual crampsAntihistamine for hives or minor allergic reactionsAntacid for upset stomach, heart burnCough drops for coughAntiseptic wipes, antibiotic ointmentSunscreen, SolarcaineHydrocortisone 0.1% cream for insect bites, mild itchingSaline eye irrigation for eye irritationLip balmNone

If your participant has any allergies to common medications or first aid supplies, please explain:

Permission to Provide Medication (for all prescription and non-prescription medication listed above):

I authorize, give permission, and request that the program nurse administer to my child, and/or assist in administering, the prescription medications listed above as prescribed. I further authorize, give permission, and recommend that the program nurse administer, and/or assist in administering, the above-authorized medications to my child on an as-needed basis.

I/We have legal authority to consent to medical treatment for the participant named above, including the administration of medication at the above referenced Program.

I certify that the foregoing information is true and complete to the best of my knowledge. I acknowledge that program nurse and staff will rely on the information provided herein to allow for the administration of medications to my child. To ensure the safety of each participant, I understand that the information I am providing will be available to appropriate program nurse and staff working with this participant to utilize with discretion.

Duty to Update

If any medical or emergency contact information changes following completion and submission of the Health and Prescription & Non-Prescription Medication Release forms, parents/legal guardians are responsible to provide program/activity staff with any updated information.

Waiver and Release

I hereby voluntarily release, waive, and forever discharge any and all claims of negligence, including but not limited to personal injuries and death, against Maryville University, the program, program nurse and program staff that relate in any way to the administration of medication(s) to my child.

Minor's Signature

Minor's Signature Date

PARENT'S OR GUARDIAN'S WAIVER

(Must be completed by all parents and guardians for participants under the age of 18)

Parent or Guardian Signature 1:

Parent/Guardian 1 Signature Date:

Parent or Guardian Signature 2:

Parent/Guardian 2 Signature Date::

Minors Programs and Activities Prescription and Non-Prescription Medication and Self-Administration and Release

Absent an acute medical emergency, all medication must be self-administered by the participant under the condition that the participant can self-manage care and delivery of medication with written authorization to do so at the program by a parent/legal guardian. All self-administration of medication must be done in the presence of an adult program staff member.

All prescription medications, including medications for conditions such as food, drug or insect allergies, diabetes, asthma, or epilepsy, as well as non-prescription medications, such as Aspirin, Tylenol, Advil, Midol, Motrin, Sudafed and cold and allergy medication must be immediately brought to the program for controlled and secured storage by the program staff or an adult camp/program staff. The only exceptions to this rule are for authorized inhalers and epi-pens which may be kept on the participants’ person.

Camp/program staff members do not assist participants in taking their prescription or non-prescription medications, nor does program/activity staff remind participants to do so.

This form must be signed by a parent/legal guardian.

Program Information

Program/Activity Name

Start Date

End Date

Participant Information

Participant Full Name

Participant Date of Birth

Prescription Medications

Please indicate below whether your child will need to take prescription medications during the program:

NoYes

Please list ALL prescription medications, dosing instructions, and any storage requirements for each medication.

Non-Prescription Medications (known and unforeseeable need)

In the event it is known that a participant will require delivery of non-prescription medication over the course of the camp/program, a parent/legal guardian must provide a signed, written authorization or note including:
The participant’s name
The non-prescription medication
Dosing instructions
Acknowledgment of no known allergies of the participant to the medication
Assurance that the participant has been instructed by the parent or legal guardian in self-medication.

In the event of minor injuries or ailments participants may incur during the program, the program staff may provide the following over-the-counter medications (or their generic equivalents) for the symptoms indicated after checking this form and attempting to contact a participant’s parent or legal guardian.

Please check all OTC medications that the program staff MAY provide to your participant on an as-needed basis:

If your participant has any allergies to common medications or first aid supplies, please explain:

Permission to Provide Medication (for all prescription and non-prescription medication listed above):

I authorize, give permission to, and recommend self-medication by my child for all medications identified above. I also affirm that he/she has been instructed in the proper self-administration of the above-identified medications by his/her attending physician (for prescription medications) and by a physician and/or parent/legal guardian (for non-prescription medications).

I/We have legal authority to consent to medical treatment for the participant named above, including the administration of medication at the above referenced Program.

I certify that the foregoing information is true and complete to the best of my knowledge. I acknowledge that program staff will rely on the information provided herein to allow for self-administration of medications by my child. To ensure the safety of each participant, I understand that the information I am providing will be available to appropriate program staff working with this participant to utilize with discretion.

Duty to Update

If any medical or emergency contact information changes following completion and submission of the Health and Prescription & Non-Prescription Medication Release forms, parents/ legal guardians are responsible to provide program/activity staff with any updated information.

Waiver and Release

I hereby voluntarily release, waive, and forever discharge any and all claims of negligence, including but not limited to personal injuries and death, against Maryville University, program staff that relate in any way to my child’s self-administration of medication(s).

Minor's Signature

Minor's Signature Date

PARENT'S OR GUARDIAN'S WAIVER

(Must be completed by all parents and guardians for participants under the age of 18)

Parent or Guardian Signature 1:

Parent/Guardian 1 Signature Date:

Parent or Guardian Signature 2:

Parent/Guardian 2 Signature Date::

Assumption of Risk, Release, and Waiver of Liability Agreement

(“Event”), I hereby agree to release, hold harmless, and discharge UNIVERSITY, on behalf of myself, my children, my parents, my heirs, assigns, personal representatives and estate as follows:

1. I acknowledge that my participation in the Event entails known and unanticipated risks, which could result in physical or emotional injury, paralysis, death, or damage to myself, to property, or to third parties. I further understand that the Event involves and that the Event may involve travel by University vehicle and/or car/shuttle service by an authorized, licensed adult driver to various locations on Maryville University property. I understand that such risks simply cannot be eliminated.

2. I expressly agree and promise to accept and assume all of the risks existing in this Event. My participation in this Event is purely voluntary, and I elect to participate despite the risks. I further certify that I am willing to assume the risk of any medical or physical condition I may have. I hereby give my consent for any medical treatment that may be required, as determined by a medical professional at the medical facility, during my participation in the Event, with the understanding that the cost of any such treatment will be solely my responsibility.

3. I hereby voluntarily release, waive, and forever discharge any and all claims of negligence against UNIVERSITY that relate in any way to any activity I undertake in conjunction with the Event, including transportation to and from the Event.

4. Should UNIVERSITY or anyone acting on its behalf, be required to incur attorney’s fees and costs to enforce this Agreement, I agree to indemnify, defend, and hold them harmless for all such fees and costs.

5. I understand that UNIVERSITY does not maintain an insurance policy that would provide coverage in the event that I am injured during the Event or cause any injury during the Event. I certify that I have adequate insurance to cover any injury or damage I may cause or suffer while participating in the Event, or else I agree to bear the costs of such injury or damage myself.

6. I understand that UNIVERSITY may photograph, film, and/or record (“Medium”) my participation in the Event. I authorize UNIVERSITY to use Medium and my likeness in conjunction with any UNIVERSITY marketing and/or promotional materials, including, but not limited to, social media accounts. I understand that I will not be compensated in any way for such use.

In the event that I file a lawsuit against UNIVERSITY, I agree to do so solely in the State of Missouri, and I further agree that the substantive law of Missouri shall apply without regard to conflict of law rules. I agree that if any portion of this Agreement is found to be void or unenforceable, the remaining portions shall remain in full force and effect.

By signing this document, I expressly state that I have sufficient opportunity to read this entire Agreement. I further certify that I have read and understood it, and I agree to be bound by its terms.

I further acknowledge that this document contains a negligence waiver and indemnification provisions.

Participant's Agreement

Participant Full Name

Today's Date

Participant Date of Birth

Participant Phone

Participant Address

Parents'/Guardians' Waiver

This section must be completed by all parents and guardians for participants under the age of 18.

In consideration of:

Minor's Full Name

Parent/Guardian 1 Full Name

Date

Parent/Guardian 2 Full Name

Date

Any signature (including any electronic symbol or process which indicates an intent to sign or authenticate this form) shall have the same legal validity and enforceability as a manually executed signature on a paper-based record to the fullest extent permitted by applicable law, including the Federal Electronic Signatures in Global and National Commerce Act, Missouri Revised Statute Section 432.230, or any similar state law based on the Uniform Electronic Transactions Act.

Maryville University Assumption of Risk, Release, and Waiver of Liability Agreement for Partner Programs

(“Event”), I on behalf of myself, my children, my parents, my heirs, assigns, personal representatives, and estate, agree as follows:

Some or all of the Event will be held at the University, but I understand and acknowledge that the Event is primarily designed, operated, supervised, or sponsored by _________________ (“PROGRAM”). I understand that PROGRAM is an independent third-party, and that PROGRAM has partnered with UNIVERSITY to hold the Event.
I acknowledge that my participation in the Event entails known and unanticipated risks, which could result in physical or emotional injury, paralysis, death, or damage to myself, to property, or to third parties. I understand that such risks simply cannot be eliminated. I further certify that I am willing to assume the risk of any medical or physical condition I may have.
I expressly agree and promise to accept and assume all of the risks existing in this Event. My participation in this Event is purely voluntary, and I elect to participate despite the risks. I hereby give my consent for any medical treatment that may be required, as determined by a medical professional at the medical facility, during my participation in the Event, with the understanding that the cost of any such treatment will be solely my responsibility.
I hereby voluntarily release, waive, and forever discharge any and all claims of negligence against UNIVERSITY and PROGRAM that relate in any way to any activity I undertake in conjunction with the Event, including transportation to and from the Event.
Should UNIVERSITY, PROGRAM, or anyone acting on UNIVERSITY’S or PROGRAM’S behalf, be required to incur attorney’s fees and costs to enforce this Agreement, I agree to indemnify, defend, and hold them harmless for all such fees and costs.
I understand that neither UNIVERSITY nor the PROGRAM maintains an insurance policy that would provide coverage in the event that I am injured during the Event or cause any injury during the Event. I certify that I have adequate insurance to cover any injury or damage I may cause or suffer while participating in the Event, or else I agree to bear the costs of such injury or damage myself.
I understand that UNIVERSITY and/or PROGRAM may photograph, film, and/or record (“Medium”) my participation in the Event. I authorize UNIVERSITY and/or PROGRAM to use Medium and my likeness in conjunction with any UNIVERSITY and/or PROGRAM marketing and/or promotional materials, including, but not limited to, social media accounts. I understand that I will not be compensated in any way for such use.

In the event that I file a lawsuit against UNIVERSITY and/or PROGRAM, I agree to do so solely in the State of Missouri, and I further agree that the substantive law of Missouri shall apply without regard to conflict of law rules. I agree that if any portion of this Agreement is found to be void or unenforceable, the remaining portions shall remain in full force and effect.

By signing this document, I expressly state that I have had sufficient opportunity to read this entire Agreement.

I further certify that I have read and understood it, and I agree to be bound by its terms.

I further acknowledge that this document contains a negligence waiver and indemnification provisions.

Participant's Agreement

Participant Full Name

Today's Date

Participant Date of Birth

Participant Phone

Participant Address

Parents'/Guardians' Waiver

This section must be completed by all parents and guardians for participants under the age of 18.

In consideration of:

Minor's Full Name

Parent/Guardian 1 Full Name

Date

Parent/Guardian 2 Full Name

Date

Any signature (including any electronic symbol or process which indicates an intent to sign or authenticate this form) shall have the same legal validity and enforceability as a manually executed signature on a paper-based record to the fullest extent permitted by applicable law, including the Federal Electronic Signatures in Global and National Commerce Act, Missouri Revised Statute Section 432.230, or any similar state law based on the Uniform Electronic Transactions Act.

Assumption of Risk, Release, and Waiver of Liability Agreement

("Event") on the date of

Start Date

End Date

I hereby agree to release, hold harmless, and discharge UNIVERSITY, on behalf of myself, my children, my parents, my heirs, assigns, personal representatives and estate as follows:

activities held indoors, personal proximity to Event staff, personal proximity to Event participants, personal proximity to other persons present at the Event’s location, shared meals, adherence to social distancing practices, and travel.

actividades realizadas en el interior, proximidad con el personal del evento, proximidad personal con otras personas presentes en el lugar del evento, comidas compartidas, adherencia a las prácticas de distanciamiento social y viajes.

and travel by University vehicle and/or car/shuttle service by an authorized, licensed adult driver to and from the Event. I further understand that some of such activities will not take place on Maryville University’s property. I understand that such risks simply cannot be eliminated.

2. I agree to follow all rules and policies of the Event. I further understand that UNIVERSITY may ask me to leave the Event immediately for failing to adhere to any rule or policy, in the sole discretion of the director(s) of the Event.

3. I expressly agree and promise to accept and assume all of the risks existing in this Event. My participation in this Event is purely voluntary, and I elect to participate despite the risks. I further certify that I am willing to assume the risk of any medical or physical condition I may have. I hereby give my consent for any medical treatment that may be required, as determined by a medical professional at the medical facility, during my participation in the Event, with the understanding that the cost of any such treatment will be solely my responsibility.

4. I hereby voluntarily release, waive, and forever discharge any and all claims of negligence against UNIVERSITY that relate in any way to any activity I undertake in conjunction with the Event, including transportation to and from the Event.

5. Should UNIVERSITY or anyone acting on its behalf, be required to incur attorney’s fees and costs to enforce this Agreement, I agree to indemnify, defend, and hold them harmless for all such fees and costs.

6. I understand that UNIVERSITY does not maintain an insurance policy that would provide coverage in the event that I am injured during the Event or cause any injury during the Event. I certify that I have adequate insurance to cover any injury or damage I may cause or suffer while participating in the Event, or else I agree to bear the costs of such injury or damage myself.

7. I understand that UNIVERSITY may photograph, film, and/or record (“Medium”) my participation in the Event. I authorize UNIVERSITY to use Medium and my likeness in conjunction with any UNIVERSITY marketing and/or promotional materials, including, but not limited to, social media accounts. I understand that I will not be compensated in any way for such use.

I further acknowledge that this document contains a negligence waiver and indemnification provisions.

Participant's Agreement

Participant Full Name

Today's Date

Participant Date of Birth

Participant Phone

Participant Address

Parents'/Guardians' Waiver

This section must be completed by all parents and guardians for participants under the age of 18.

In consideration of:

Minor's Full Name

Parent/Guardian 1 Full Name

Date

Parent/Guardian 2 Full Name

Date

Any signature (including any electronic symbol or process which indicates an intent to sign or authenticate this form) shall have the same legal validity and enforceability as a manually executed signature on a paper-based record to the fullest extent permitted by applicable law, including the Federal Electronic Signatures in Global and National Commerce Act, Missouri Revised Statute Section 432.230, or any similar state law based on the Uniform Electronic Transactions Act.

Assumption of Risk, Release, and Waiver of Liability Agreement

("Event") , I hereby agree to release, hold harmless, and discharge UNIVERSITY, on behalf of myself, my children, my parents, my heirs, assigns, personal representatives and estate as follows:

activities held indoors, personal proximity to Event staff, personal proximity to Event participants, personal proximity to other persons present at the Event’s location, shared meals, adherence to social distancing practices, and travel.

actividades realizadas en el interior, proximidad con el personal del evento, proximidad personal con otras personas presentes en el lugar del evento, comidas compartidas, adherencia a las prácticas de distanciamiento social y viajes.

I further understand that some of such activities will not take place on Maryville University’s property and that the Event involves travel by University vehicle and/or car/shuttle service by an authorized, licensed adult driver to and from various locations, as designated below. I understand that such risks simply cannot be eliminated. I consent to my participation in and transportation to and from the Event at the locations listed below.

I further acknowledge that this document contains a negligence waiver and indemnification provisions. I further understand that this document may bar a lawsuit or any other legal claim that I may have against UNIVERSITY.

Participant's Agreement

Participant Full Name

Today's Date

Participant Date of Birth

Participant Phone

Participant Address

Parents'/Guardians' Waiver

This section must be completed by all parents and guardians for participants under the age of 18.

In consideration of:

Minor's Full Name

Parent/Guardian 1 Full Name

Date

Parent/Guardian 2 Full Name

Date

Any signature (including any electronic symbol or process which indicates an intent to sign or authenticate this form) shall have the same legal validity and enforceability as a manually executed signature on a paper-based record to the fullest extent permitted by applicable law, including the Federal Electronic Signatures in Global and National Commerce Act, Missouri Revised Statute Section 432.230, or any similar state law based on the Uniform Electronic Transactions Act.

Payment

Cardholder Information

First Name

Last Name

Phone

Billing Street

Billing City

Billing State

Billing Zip

Billing Country

Card Information

Credit Card Number

Credit Card Security Code

(CVV/CSC)

Expiration Month

Expiration Year

Charge Information

Total Charge

Camp Name

Authnet_Hidden_Fields

Contact Information

2024 Camp Registration Form

Minor Program and Activities Medical Form Health History, Immunizations, Permission for Emergency Treatment

Please check any of the following that apply and note next to each the diagnosis and date when the condition started.

Immunization against infectious diseajeprotect the individual against personal infection and reduces the risk of contagious disease for all PROGRAM participants. The University strongly recommends parents ensure that their child's immunizations are up to date with current CDC recommendations.

The following vaccinations (which most children in the United States should have had as part of their regular vaccinations during childhood) are recommended:

Measles, Mumps, and Rubella vaccine (MMR)Diptheria/Tetanus/Pertussis vaccine (DPT, DTAP)Varicella (chickenpox) vaccine Polio vaccine (IPV)Hepatitis B vaccine seriesFor students entering Grade 8 or higher: Meningococcal conjugate vaccine (MCV4) and TDAP

Entering Grade 8 or higher only:

In the event of a medical emergency, it is often helpful for the Program to have a minor's medical insurance information to give to the healthcare provider. Providing this information to the Program is optional.

Program Consent/Permission for Emergency Medical Treatment and Sharing of Medical Information

PARENT'S OR GUARDIAN'S WAIVER

ASSUMPTION OF RISK FORM REGARDING COMMUNICABLE DISEASE TRANSMISSION

EPI-Pen Form & Release

PERMISSION TO ADMINISTER EPI-PEN & RELEASE AND WAIVER OF LIABILITY AGREEMENT

PARENT'S OR GUARDIAN'S WAIVER

Minors Program or Activity Media, Photo and Video Release Form

PLEASE READ THIS DOCUMENT CAREFULLY BEFORE SIGNING. THIS IS A LEGALLY BINDING DOCUMENT.

PARENT'S OR GUARDIAN'S WAIVER

DISCIPLINARY PROCEDURES AND CODE OF CONDUCT FOR YOUTH PROGRAMS AND CAMPS

Code Of Conduct For Minor Participants

Minors Programs and Activities Prescription and Non-Prescription Medication Requirements and Release for Nurse Administration

Permission to Provide Medication (for all prescription and non-prescription medication listed above):

PARENT'S OR GUARDIAN'S WAIVER

Minors Programs and Activities Prescription and Non-Prescription Medication and Self-Administration and Release

Permission to Provide Medication (for all prescription and non-prescription medication listed above):

PARENT'S OR GUARDIAN'S WAIVER

Assumption of Risk, Release, and Waiver of Liability Agreement

Maryville University Assumption of Risk, Release, and Waiver of Liability Agreement for Partner Programs

Assumption of Risk, Release, and Waiver of Liability Agreement

Assumption of Risk, Release, and Waiver of Liability Agreement

Payment

Measles, Mumps, and Rubella vaccine (MMR)
Diptheria/Tetanus/Pertussis vaccine (DPT, DTAP)
Varicella (chickenpox) vaccine
Polio vaccine (IPV)
Hepatitis B vaccine series
For students entering Grade 8 or higher: Meningococcal conjugate vaccine (MCV4) and TDAP