2019 Summer Engineering Technology Program School...
Transcript of 2019 Summer Engineering Technology Program School...
2019 Summer Engineering Technology Program
School Counselor Recommendation Form
The following questions should be answered by the student applicant’s school counselor and turned in by May 31.
Name of student: __________________________________
The student has applied to the Summer Engineering Technology program offered at Florida Atlantic University,
Boca Raton campus Summer 2019.
GPA: _____
Do you recommend this student for the program: Yes ____ No ____
Comments: ___________________________________________________________________________________
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Signature: Date: _________________________________________
PLEASE FAX OR SCAN & EMAIL BY MAY 31 TO:
Florida Atlantic University
Division of Engineering Student Services & Advising
Att.: Evelyn Chang-Cruzpino
777 Glades Road EE 102
Boca Raton, FL 33431
Fax: 561.297.2781
Email: [email protected]
Marketing and Creative Services777 Glades Road, Boca Raton, FL 33431-0991
tel: 561.297.2080 • fax: 561.297.2307 • [email protected] • www.fau.edu
Boca Raton • Dania Beach • Davie • Fort Lauderdale • Harbor Branch • Jupiter • Treasure CoastAn Equal Opportunity/Equal Access Institution
PHOTO/VIDEO RELEASE FORM
I hereby give permission for the name, likeness and biographical material of the minor child listed below to be used solely for the purposes of Florida Atlantic University-related promotional mate-rial and publications and waive any rights of compensation or ownership thereto.
___ Student ___ Faculty ___ Staff ___ Other
Name of Minor (please print): __________________________________________________________
Address: ____________________________________________________________________________
City: ___________________________________ State:________________ ZIP: ___________________
Name of Parent/Guardian: _____________________________________________________________
Parent/Guardian Signature: ___________________________________ Date: ____________________
Phone number:_____________________________ Email: ___________________________________
OFFICE USE ONLY:M F • W B H A O__________ HR__________ TOP: ______________ BOT: ______________
Participant under 18 years old
Florida Atlantic University Permission and Release of Liability
Pre-collegiate Programs
I, , am the parent and/or legal guardian of , a minor child under the age of 18
years.
I would like to have my child participate in the Summer Engineering Technology Program at Florida Atlantic University (FAU).
In consideration for my child being allowed to participate in this PRE-COLLEGIATE PROGRAM, I the undersigned, acknowledge, appreciate and agree that:
1. I choose to voluntarily allow my child to participate in this PRE-COLLEGIATEPROGRAM. I voluntarily assume full responsibility for any risk of loss,property damage or personal injury, which may be sustained by my child as aresult of his/her participation.
2. I certify that I have adequate health insurance necessary to provide for and pay forany medical costs that may directly or indirectly result from my child’sparticipation in this PRE- COLLEGIATE PROGRAM. I agree to pay for anymedical costs that exceed the limits of my insurance coverage.
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I do not have medical insurance, but understand the University is not responsible for medical expenses that may directly or indirectly result from my child’s participation in this PRE- COLLEGIATE PROGRAM.
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I hereby release, waive, and discharge Florida Atlantic University and its Board of Trustees, its officers, agents, employees and representatives from all claims, demands, liabilities, rights and causes of action of whatever kind or nature, that may result from or occur during my child’s participation in the Summer Engineering Technology Program, whether caused by negligence of the UNIVERSITY, its Board of Trustees, officers, agents, employees or representatives or otherwise. I also agree to indemnify and hold harmless the UNIVERSITY for any loss, liability, damage or costs, including court costs and attorney’s fees that may occur as a result of my or my child’s negligent or intentional act or omission while participating in the Summer Engineering Technology Program.
I HAVE CAREFULLY READ THIS PERMISSION AND RELEASE OF LIABILITY AND HAVE HAD SUFFICIENT TIME TO SEEK EXPLANATION OF THE PROVISIONS CONTAINED HEREIN, AND TO DISCUSS ANY QUESTIONS OR CONCERNS I MAY HAVE WITH THE UNIVERSITY OR ITS AFFILIATE. AFTER CAREFUL CONSIDERATION, I SIGN THIS DOCUMENT VOLUNTARILY AND WITHOUT ANY INDUCEMENT.
___________________________________________ _______________ Signature of Parent and/or Legal Guardian Date
___________________________________________ _______________ Signature of Parent and/or Legal Guardian Date
Florida Atlantic University Pre-collegiate Program Health Examination Form
Prime Soccer Enterprise Inc./ Goal to Goal, FAU Soccer Camps
THE FIRST PAGE AND TOP OF SECOND PAGE TO BE COMPLETED BY PARENT OR GUARDIAN. FORM
MUST BE SIGNED AND DATED.
(SEE PARENT’S AUTHORIZATION & PERMISSION TO TREAT)
Participant Name_______________________________________________________________________
Birth Date ___________________ Sex _________ Age _______
Parent or Guardian (or Spouse) ___________________________________________________________
Phone: Day (______)____________ Evening (______)________________ Cell (_____) _______________
Home Address_________________________________________________________________________
Street & Number City State Zip
If not available in an emergency, notify:
1. Name_________________________________________ Relationship to Camper_________________
Home Phone ( )_______________ Work Phone ( )______________ Cell Phone ( )_______________
2. Name_________________________________________ Relationship to Camper_________________
Home Phone ( )_______________ Work Phone ( )______________ Cell Phone ( )_______________
HEALTH HISTORY:
(Check if the participant has had any of the following – giving approximate dates where applicable.)
ALLERGIES:
Ear Infections __________________ Chicken Pox ________________ Hay Fever ____________________
Asthma _________________ Rheumatic Fever ______________ Ivy Poisoning etc. _________________
Seizures __________________ Chest Pain _______________________ Diabetes ___________________
Passing out upon exertion _____________________ Penicillin _________________________________
Insect Stings _______________________ Food _____________________________
(Please provide specific details below.)
Details of Allergies Above (frequency, severity, triggers) and include any additional medication or food
allergies.
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Operations or Serious Injuries
(Dates)_______________________________________________________________________________
Chronic or Recurring Illness_______________________________________________________________
SUGGESTIONS FROM PARENTS:
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IMMUNIZATION RECORD…CAMPERS CANNOT BE ACCEPTED WITHOUT THIS INFORMATION
Required immunizations must determined locally. This is a record of dates of basic immunizations and
most recent booster doses.
DTP Series ___________ booster ___________ Tetanus booster (within the last 10 years) ____________
Polio IPV ____________ booster ______________ MMR ______________________________________
Hepatitis B __________________________ Varicelle (chicken pox)_______________________________
Other state or municipal examinations required if any)_________________________________________
MEDICATIONS THAT MUST BE TAKEN – to be completed and signed by a parent or legal guardian
____ This person takes NO medications on a routine basis.
____ This person takes medications as follows (attach additional pages if needed):
Medication: Dosage: Times taken each day: Reason for taking:
THIS MUST BE SIGNED FOR CHILD TO ATTEND CAMP
PARENT AUTHORIZATION & PERMISSION TO TREAT: This health history is correct so far as I know, and
the person herein described has permission to engage in all prescribed camp activities, except as noted
by me and the examining physician. I hereby give permission to seek and authorize necessary medical
care in the event of an emergency. In the event that I cannot be reached in an emergency, I hereby give
permission to the physician to provide treatment, including hospitalization, for the person named
above.
Parent/Guardian Signature_______________________________________ Date____________________
MEDICAL EXAMINATION to be completed and signed by licensed medical personnel
Hgt: __________________________ Wgt: __________________________ B.P.:
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The applicant is under the care of a physician for the following conditions:
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(For Girls and Women) Has this person menstruated?____ If so, is her menstrual history normal?______
Special considerations___________________________________________________________________
Recommendations and restrictions while in camp_____________________________________________
Known allergies________________________________________________________________________
Special meal plans or diet restrictions______________________________________________________
Medications to be administered at camp (name, dosage, frequency if different from above):
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Limitations or restriction on camp activities__________________________________________________
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Additional information for camp health care personnel________________________________________
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I examined this individual on _____________________(date). In my opinion, the applicant is able to
participate in an active camp program.
SIGNATURE OF LICENSED MEDICAL PERSONNEL_____________________________________________
Print Name_________________________________________________________________________
Title_______________________________________________________________________________
Address____________________________________________________________________________
Telephone__________________________________________________________________________
Date_______________________________________________________________________________