June 10 – 15, 2018
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:______Gender______
Last/First/Middle
Home Address:______
Street/City/Zip 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
Special Diet Needs? Yes No
Join our group, “Teen Institute for Deaf/Hard of Hearing 2018”.
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_____
I am: Deaf Hard of HearingHearing CODA Hearing (Deaf family)
T-Shirt size (Adult): 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 2018; 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 teen to attend the Teen Institute because:______
______
______
______
______
______
______
______
______
______
Has your teen 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 DeafLEAD when returning this application.
I have examined the program and philosophy of the T.I. I agree to allow my teen 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 21, 2018 -
After May 21, the fee will increase to $100.00.
**Application will not be accepted after June 7, 2018**
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PART III: STUDENT & PARENT/GUARDIAN
RULES OF CONDUCT
For our TI to be the safe and great 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, bedrooms, 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 advertising beer or drugs (i.e., Budweiser or Marijuana) are allowed.
8. No alcohol or other drugs (other than prescription) are 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, the camper gambling will be sent 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. Parents will be called if you break the rules, which may result in being sent home from camp at your expense.
11. Participants must agree to respect the rules of the campsite.
I have read the rules of conduct and discussed with my teen. I also understood that my teen will discuss the rules in their group and sign the rules of conduct form.
Student’s signature Parent’s signature
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PART IV – SCHOOL COUNSELOR OR FACULTY SPONSOR
Name(s)______Position/Title______
Mailing Address______
Street/City/Zip 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 them should they be selected. I agree to assist them wherever possible in using the skills and knowledge learned at TI and to be supportive of their efforts in prevention.
Signed:______
School Counselor or Faculty Sponsor
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PART V:TO BE COMPLETED BY PARENT/GUARDIAN
BE SURE TO SIGN IN ALL FOUR PLACES
DeafLEAD
2505 W. Ash
Columbia, MO 65203
TEEN INSTITUTE
Health Form -- Publicity Form
Teen’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: ______-5-
TEEN INSTITUTE HEALTH FORM
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 6 Below
This heath history is correct as far as I know, and my teen 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
DeafLEAD carries accident and injury insurance.
Medication Authorization (These cannot be given without your authorization).
I authorize the nurse to administer to my teen,
Name ______, the medication prescribed by ______
(Doctor’s Name)
Office # ( )______for the period from June 10– June 15, 2018 (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
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Parent Release Form
SURVEY AND PUBLICITY RELEASE
Parent’s Signature is Required Two Times on Page 7 Below
A pre- and post- test will be given to students to measure the impact of TI. I authorize DeafLEAD 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 teen for promotional and/or publicity purposes about TI 2018.
______
Name of Student Date
______
TI Participant’s Signature Parent’s Signature
LIABILITY RELEASE
I hereby release DeafLEAD -- Teen Institute on Substance Abuse, any of its sponsoring or cooperating agencies, Garrison’s River Retreat, and any other persons or organizations associated or involved with TI 2018 to be held at Garrison’s River Retreat June 10 - June 15, 2018 from any and all liability during said Institute. I also certify that health and accident insurance cover my teen for any accident or injury that may occur while at or in route to and from the Institute.
______
Date Parent’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
DeafLEAD
2505 W. Ash St.
Columbia, MO 65203
Teen Institute is sponsored by
The State of Missouri
Department of Mental Health
Division of Behavioral Health
DeafLEAD
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PARTICIPANT HEALTH HISTORY FORM
Participant Name: Email Address:
Address:City/State/Zip:
Phone: Day: Evening:
Gender: Male Female Date of Birth:
Emergency Contact Name: Relationship:
Phone: Day: Evening:
Current medicationsother medical alert information:
Allergies:
Are you younger than 18 years old?∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ YES NO
If YES, you need to have a parent/guardian sign the Release of Liability and Medical Release Formin order toparticipate.
Do you require an inhaler for Asthma attacks?∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ YES NO
If YES, it is your responsibility to make sure that your prescribed inhaler is readily available during the program.
Are you allergic to bee stings or other insect bites? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ YES NO
If YES, it is your responsibility to make sure that your prescribed medication or shot(s) are readily available during the program.
Do you have Diabetes?∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ YES NO
If YES, it is your responsibility to make sure that you have food or prescribed medication readily available during the program.
Do you have a history of seizures? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ YES NO
If YES, do you want an ambulance called if you experience a seizure while participating in this program? ∙ ∙ ∙ ∙∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ YES NO
If you have a history of heart problems or high blood pressure – You are at risk if you participate physically in this program. There is historical evidence that some individuals with pre-existing heart conditions have suffered heart attacks and death after participating in a Outdoor Program. Due to the emotional and physical demands inherent to the activities, you may be jeopardizing your health and well being if you choose to fully participate. You should consult your physician prior to attending the program.
If you arepregnant – You and your unborn child are at risk if you participate physically in this program. Unintentional impacts to your abdomen can occur during many of the activities that involve physical contact. If climbing is a part of your program, you will be required to wear a harness that puts pressure on your abdominal area and back. Due to the types of physical demands inherent to the activities, you may be jeopardizing your health and well being, as well as the health and well being of your unborn child, if you choose to fully participate. You should consult your physician prior to attending the program.
If you are recovering from broken bones, dislocated joints, sprains, strains, back or neck injuries -
You are risking re-injury if you participate physically in this program. You should consult your physician prior to attending.
If you have an enlarged organ, are a transplant recipient, or have Downs Syndrome – You are risking injury to weakened areas of your body. You should consult your physician prior to attending the program.
Participating in this program may involve bending, twisting, lifting, running, jumping, climbing, increased heart or breath rates and physical contact with others. Unexpected strains or jolts to your body can occur.
Do you have any concerns that might limit your participation in physical activity? ∙ ∙ ∙ ∙ ∙ ∙∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ YES NO
If YES, please explain:
Great Circle recommends that you do not physically participate in activities that you think might put you at risk. If you are concerned, your Facilitator can provide you with a less physical way to stay involved.
Do you anticipate needing physical assistance from us during your participation? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ YES NO
If YES, what can we do to assist you?
Do you have any current mental or psychological conditions requiring medication, treatment, or special considerations?
YES NO
If YES, please explain:
Do you have a current tetanus shot? YES NO If YES, date of last inoculation:
If you have any questions regarding your program, please contact the Great Circle office.
PARTICIPANT AGREEMENT/MEDICAL RELEASE FORM
ParticipantName (please print):
Parent/Guardian Name (please print):
Please check and sign below to indicate that you have read, understood, and agree to the statements on this form.
Parents/Guardians/Legal Representatives should check and sign on behalf of participating Minors after discussing each section with them, indicating that both the Minor and the Parent/Guardian/Legal Representative agree to each section.
I am aware that participants might be photographed and/or videotaped during activities, and authorize such photographs and/or videotapes to be used by Great Circle in training, marketing, fundraising or related promotional uses at any point in the future. I understand that my name will not be used and/or published in any way, and that I will not receive compensation for the use of such photographs and/or videotapes.I understand this consent remains in effect indefinitely unless I notify Great Circle in writing that this consent is to be discontinued.
AgreeDisagree
I give my consent to Great Circle employees and to emergency medical personnel to treat me if they deem it to be medically necessary.I authorize the Great Circle staff to secure such medical advice and services as they feel necessary for my health or well-being. I give permission for emergency anesthesia and/or surgery that might be necessary due to an illness or injury occurring during my participation.
AgreeDisagree
By signing below without checking either box, you are agreeing with each of the two statements above.
RELEASE OF LIABILITY
I understand that Outdoor and Adventure activities are, by their nature, physically and emotionally demanding, and that participating in the Great Circle program may involve risks such as bending, twisting, lifting, running, jumping, climbing, swinging, increased heart or breath rates, heights of 40 feet or more, and physical contact with others.
I understand that there are inherent risks at Meramec Adventure Learning Ranch and that some of the activities involve dangers regardless of the care taken by the Great Circle staff and that not all dangers and hazards can be (i.e. cuts, bruises, scrapes, fractures, falls, fatalities, etc.). I fully understand that there are potential risks and hazards associated with the Meramec Adventure Learning ranch, natural areas, which include bodies of water, falling/fallen timber, ruts and holes, recreational/experiential facilities, and local wildlife and livestock. I am aware that certain risks and dangers exist in the activities that are beyond the control of Great Circle and their employees, and that my presence is voluntary to be in, on, or upon the property.
I understand that I have the right and the responsibility to limit my participation in any activity that I believe will compromise my safety, and agree to notify a Great Circle employee if I have safety concerns. If I choose to physically participate in any of the activities, I voluntarily assume all risks associated with such participation.
I understand that the Great Circle staff has the right to deny my participationand that it is my responsibility as a Participant to follow the safety guidelines and procedures established by the Facilitator(s). If, at any time, I do not understand or have not heard specific instructions given by the Facilitator(s), I realize that it is my responsibility to ask for clarification and/or assistance.
I state that I am not now under the influence of any chemical substance including alcohol, and that I will not be under the influence of any substance when participating in the Great Circle program. I realize participating in all outdoor and adventure activities while under the influence of a substance would endanger others and myself.
I agree to accept financial responsibility for any medical expenses and/or loss of incomenot covered by my Insurance Policy that occurs as a result of my participation in the Great Circle program.
I understand and assume all dangers and risks (both known and unknown) associated with my participation in the Great Circle program and waive, release and discharge Great Circle Inc. and their agents, officers and employees from all claims or causes of action arising from my participation. I do hereby release Great Circle Inc., and their agents, officers, and employees from any and all liability, even if arising from the negligence of the releases, and agree to indemnify and hold Great Circle Inc. harmless for any accidents, injury, loss or damage of property, and from any legal fees that I may ever have as a direct or indirect result of participating in the Great Circle program. This release, indemnification, and waiver shall be construed broadly to the maximum extent under applicable law.
My signature on this document is also intended to bind my representatives, administrators, successors, heirs, next of kin and assigns on my behalf.
By signing below I am agreeing that I have carefully read and agree to all of the sections initialed above. I am also verifying that the information listed on the Health History Form is complete and accurate to the best of my knowledge. (Please complete the Health History Form on the other side prior to signing this document).