June 8 – 14, 2014
TEEN INSTITUTE FOR DEAF AND
HARD OF HEARING STUDENTS
INSTRUCTIONS: 1. This application has five parts.
Part I to be completed by student.
Part II to be completed by parent/guardian.
Part III to be completed by student and parent/guardian.
Part IV to be completed by appropriate faculty representatives.
Part V to be completed by parent/guardian.
2. Applications must be submitted immediately. Applications will be reviewed/accepted on
a “first-come” basis. It is best to apply as early as possible.
3. Please type or print legibly.
4. An application will NOT be considered unless FULLY COMPLETED.
PART I – STUDENT
Name:______Male ______Female______
LastFirstMiddle
Home Address:______
StreetCityZip Code
Phone: ( ) ______Date of Birth: ______Age: ______Race:______
Student Email:______
Your School: ______City: ______County:______
Expected Date of Graduation:______Current Grade Point Average: ______
Do you have a Facebook Page (circle): Yes No Are you vegetarian? (circle): Yes No
If you have Facebook, please feel free to join our group, Teen Institute for Deaf/Hard of Hearing 2014
What do you hope to learn during TI?______
______
In what school, church, or community activities have you been involved? (Please be specific)
______
______
______
I can communicate using: ASL ____ PSE/CASE ____ SEE I & II ____ Oral _____ Tactile_____
T-Shirt size: S _____M _____L _____XL ____Other _____
I have examined the program and philosophy of TI. If selected, I agree to participate in the Institute for its duration. I also agree to share with others in my school and community, as best as I can, the knowledge and skills I gain at TI. I understand, if selected for Teen Institute 2014, that I will be required to fill out a survey that will provide statistical information for future TI’s. I understand my name will be anonymous in the survey.
Signed: ______
PART II – PARENT/GUARDIAN
Name(s) ______Relationship:______
Home Address:______
StreetCityZip Code
Phone(s): ( )______Emergency Phone: ( )______
Email Address:______
I would recommend my son/daughter to attend the Teen Institute because:______
______
______
______
______
______
______
______
______
______
Has your son/daughter had any significant behavior problems during this school year?
If yes, please explain:
______
______
Are you interested in carpooling with another parent in your area? Yes No
(If yes, can we share your contact information with another parent interesting in carpooling?) Y N
**The camp registration fee is $75. Please include a check for this amount payable to The L.E.A.D. Institute when returning this application.
I have examined the program and philosophy of the T.I. I agree to allow my son/daughter to attend if selected. I further agree to be supportive of their efforts to share in their school and community skills and knowledge they will learn.
Signed:______
- Submit your application with $75 before May 2, 2014 -
After May 5, the fee will increase to $100.00.
**Application will not be accepted after June 4, 2014**
PART III: STUDENT & PARENT/GUARDIAN
RULES OF CONDUCT
In order for our TI to be the safe and wonderful experience it has always been, all participants will be expected to abide by the following rules of conduct:
1.Participants are responsible for attending all training sessions, workshops, and small groups, and being present on time.
2.Participants are responsible for keeping the campground, meeting rooms, rooms, and rest rooms clean. (Do NOT litter!)
3.Participants must be in the rooms with lights and music off by 11:00 p.m.
4.Once arrived, no one may leave the campgrounds except with written permission of the Director.
5.If participants become ill or injured, the TI Director must be notified immediately.
6.Cigarette smoking (forall campers and interns)is not permitted.
7.No inappropriate clothing such like beer or drugs (i.e., Budweiser or Marijuana) is allowed.
8.No alcohol or other drugs (other than prescription) is allowed. If found, camper will be sent home.
9.Dating, Kissing or improper hugging, or sexual behaviors will not be tolerated.
11.No gambling of any kind. If found gambling camper will be send home.
10.Visiting in cabins with friends of same sex or opposite sex is prohibited. Cabins are your home at TI and all cabin members need privacy and the chance to rest.
10.Two Strikes for violation of the rules will result a phone call to your parent &/or expel from the camp at your expenses.
11.Participants must agree to respect the rules of the campsite.
I have read the rules of conduct and discussed with my son/daughter. And I understood that my son/daughter will discuss in his/her group and sign the rules of conduct form.
Student’s signature Parent’s signature
PART IV – SCHOOL COUNSELOR OR FACULTY SPONSOR
Name(s)______Position/Title______
Mailing Address______
StreetCityZip Code
Phone(s) ______County______
To the best of your knowledge, does the applicant meet all of the admission requirement of the TI?
______
Please briefly describe why you believe this applicant is an appropriate candidate for TI?
______
______
______
Has this student had any significant behavior problems during this school year? If yes, please explain:
______
______
This student is fluent in: ______
After examining the program and philosophy of the TI, I agree to serve as a faculty liaison and sponsor for should he/she be selected. I agree to assist him/her wherever possible in using the skills and knowledge learned at TI and to be supportive of his/her efforts in prevention.
Signed:______
School Counselor or Faculty Sponsor
PART V:TO BE COMPLETED BY PARENT/GUARDIAN
BE SURE TO SIGN IN ALL FOUR PLACES
The L.E.A.D. Institute
2502 W. Ash
Columbia, MO 65203
TEEN INSTITUTE
Health Form -- Publicity Form
Son/Daughter’s Name ______Date of Birth ______Sex _____ Age ____
Parent/Guardian Name (s):______
Home Address: ______
# and StreetCity State/Zip
Home Phone:( )______Father’s Work # ( )______Mother Wk # ( )______
Insurance Co: Policy # Insurance Phone #
If not available in an emergency notify:
1. Name: ______Home Phone ( ) ______
Work Phone ( ) ______
Relationship to Student: ______
2. Name:______Home Phone ( ) ______
Work Phone ( ) ______
Relationship to Student: ______
Name of Physician: ______Office Phone ( ) ______
Physician’s Address: ______Exchange # ______
HEALTH HISTORY (check - give approximate dates) ALLERGIES:
Ear Infection______Sun Sensitivity ______
Rheumatic Fever ______Hay Fever ______
Convulsions ______Ivy Poisoning, etc. ______
Diabetes ______Insect Stings ______
Urinary Frequency______Penicillin ______
Headaches______Other Drugs ______
Dizziness______Foods ______
Leg/Joint Pains______DISEASES:
Sore Throats______Chicken Pox ______
Hearing Loss______Measles ______
Hoarseness/Cough______German Measles (Rubella) ______
Speech Problems______Fifths Disease ______
Shortness of Breath______Mumps ______
Nose Bleeds______Asthma ______
Fainting______MENTAL HEALTH OR ADDITIONAL INFORMATION:
Dental (bridges, false teeth)______
Visual Deficits (glasses, contacts) ______
Date of Most Recent Tetanus Booster: ______
Have You had a Hepatitis B Shot/Series?
YES ___ NO ___ Date: ______
TEEN INSTITUTE HEALTH FORM
-2-
Operations or Serious Injuries:Any Physical Activity Limitations:
(Dates)______
Chronic or Recurring Illnesses:Any Dietary Limitations while at TI:
(Dates) ______
Other Diseases or Additional Information: ______
PARENT’S AUTHORIZATION
Parent’s or Guardian’s Signature is REQUIRED TWICE on PAGE 2 Below
This heath history is correct as far as I know, and my child has permission to engage in all TI activities as noted.
Please be assured that if emergency medical treatment is needed, a parent or parent designee will be notified immediately. However, in the event of an emergency where a parent or parent designee cannot be reached, I hereby give my permission to the camp director and authorized representatives to secure proper treatment for (including hospitalization, anesthesia, and surgery) for
______
Student’s name
______
DateParent’s Signature
Insurance Information
The L.E.A.D. Institute carries accident and injury insurance.
Medication Authorization (These cannot be given without your authorization).
I authorize the nurse to administer to my son/daughter,
Name ______, the medication prescribed by ______
(Doctor’s Name)
Office # ( )______for the period from June 8– June 14, 2014 (or other date(s) specified: ______
**** SEND IN PHARMACY LABELED CONTAINERS ONLY ***
Name of Drug: ______Amount to be given: ______
Time of day to be given: ______
Name of Drug: ______Amount to be given: ______
Time of day to be given: ______
For minor ailments, I authorize administration of the following medications: (Please check)
______Antibiotic Ointment______Antacid ______Decongestant______Antidiarrheal
______Calamine Lotion______Ibuprofen or Tylenol (325 mg. 1 or 2 tablets. (Please circle)
______
DateParent’s Signature
-3-
Parent Release Form
SURVEY AND PUBLICITY RELEASE --- Parent’s Signature is Required Two Times on Page 3 Below
A pre- and post- test will be given to students to measure the impact of TI. I authorize the L.E.A.D. Institute to administer these evaluation tools to measure knowledge, skills and attitudes about alcohol, tobacco and other drugs.
I also authorize the Teen Institute on Substance Abuse and its staff to use the name and/or photograph of my son/daughter for promotional and/or publicity purposes about TI 2014.
______
Name of StudentDate
______
TI Participant’s SignatureParent’s Signature
LIABILITY RELEASE
I hereby release the L.E.A.D. Institute -- Teen Institute on Substance Abuse, any of its sponsoring or cooperating agencies, Missouri School for the Deaf, and any other persons or organizations associated or involved with TI 2014 to be held at Missouri School for the Deaf June 8 - June 14, 2014 from any and all liability during said Institute. I also certify that health and accident insurance cover my son/daughter for any accident or injury that may occur while at or in route to and from the Institute.
______
DATEParent’s Signature
DO WE HAVE THE PARENT’S (GUARDIAN’S) SIGNATURE Four (4) TIMES ON THIS FORM????
PLEASE RETURN COMPLETED FORM TO:
Becky Beck, Teen Institute Coordinator
The L.E.A.D. Institute
2502 W. Ash
Columbia, MO 65203
Teen Institute is sponsored by
The State of Missouri
Department of Mental Health
Division of Behavioral Health
The L.E.A.D. Institute
Teen Institute 2014 Field Trip to Garrison’s River Resort
Parental/Guardian Consent Form and Liability Waiver
Participant’s Name:______Birth Date:
Parent/Guardian’s Name:
Home Address:
Best Phone #:(Please circle which type)CellWorkVP
E-Mail:
Arrival:
On Sunday, June 8, 2014 I prefer to: (please initial the option you would like)
Drop my child off at Garrison’s River Resort in Steelville, Missouri between 1-2p (State HWY TT & Garrison Lane, Steelville, MO 1-800-367-8945) (directions will be included in child’s letter)
Drop my child off at the Missouri School for the Deaf between 9-11a (bus will leave by 11:30a, to transport to Steelville, MO) (505 5th, Fulton, MO directions will be included in child’s letter)
Departure:
On Saturday, June 14, 2014, I will pick my child up at the Missouri School for the Deaf between 2p-3p. (505 5th, Fulton, MO directions will be included in child’s letter)
I, (Parent/Guardian)______, grant permission for my child, (Child’s name), ______, to participate in a three night field trip to Garrison’s River Resort, in Steelville, MO on June 8-12, 2014 that requires transportation from the Missouri School for the Deaf where the Teen Institute summer camp is located. I understand that my child will be transported by bus to/from Garrison’s River Resort and will be under the guidance of the staff of The L.E.A.D. Institute and volunteers of the Teen Institute. I also understand that my child will be engaging in activities such as river floating, swimming, campfires, fishing, and team building activities.
I permit my child to go horseback riding (for an additional cost of $15.00) while at Garrison’s River Resort. Yes No Child can bring $15.00 cash or make the check out to Garrison’s River Resort
I permit my child to float in a 5-10 person raft while at Garrison’s River Resort. Yes No
As parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above named minor participant. I agree on behalf of myself, my child named herein, or our heirs, successors and assigns, to hold harmless and defend the Teen Institute and The L.E.A.D. Institute, its officers, director and staff, and the Corporation of The L.E.A.D. Institute, chaperones, or representatives associated with the field trip, from any and all actions, claims, demands, damages, costs, expenses, and all consequential damage arising from or in connection with my child attending the trip or in connection with any illness or injury or cost of medical treatment in connection therewith.
Signature of Parent/Guardian:______Date:______