2024 Summer Adventures at the Indiana Academy

Level (hidden)

Parent/Guardian Information

Parent/Guardian Type

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Email

Parent/Guardian Phone

Mailing Address

Country

Street

City

Region

Postal Code

Camper Information

Registering sibling(s) for the camp?

Yes

No

If yes, please enter full names here and then make sure to submit a separate registration form for each sibling.

First Name

Preferred First

Last Name

Email Address

Confirm Email Address

Birthdate

Sex

Female

Male

X or another legal sex

Pronouns

These are how you want to be addressed when someone is speaking with you. Again, with the recognition that these may be fluid, you will be able to change your pronouns at any time you choose.

Gender Identity

This is what you feel like and how you identify but may not outwardly demonstrate. This may not align with the sex that you were assigned at birth.

Phone Type

Phone Number

Text Message Opt In

Yes

No

Mailing Address

Country

Street

City

Region

Postal Code

School Information

Search by the full school name, if you do not see the name search again by city and state.

If you are home schooled enter "Home School Clearing House".

Middle or High School Name

(hidden) CEEB

Expected High School Graduation Year

Grade Level for Fall 2024 (6,7,8,9,10)

Additional Information

T-Shirt Size

Camp Format (Select one)

Full Day

AM only

PM only

Lunch (Optional) for additional $20 for the week

Yes

No

*Summer Adventures camp will need to meet minimum enrollment to operate. If it does not meet the minimum enrollment, it may be canceled.

Information and Authorization for Medical Care

As a parent or guardian, I understand that the information requested on this form is intended to help inform program staff of any pre-existing medical conditions my Child may have. If my Child has a pre-existing medical condition, participation in any strenuous activities or recreational time may not be recommended. Ball State University requests the information below so that, in case of emergency, we will have accurate information so that we can provide and/or seek appropriate treatment for your Child. You are accountable for providing an accurate medical history. Final determination about whether Child should participate is the responsibility of you and your physician. If your Child has any medical issue that is not requested below, but which you think is important, please include that information. It is recommended that you consult with a physician prior to your Child’s participation in this Program. If you are uncertain about any preexisting medical conditions, it is your responsibility to consult with your own physician prior to your Child’s participation in this Program. Please answer all of the questions. If you answer yes to any of the following questions, please explain as indicated. Use back and/or additional paper if needed.

I understand that Ball State University does not provide any health insurance for my Child while participating in the Program.

I have read and agree with the Information and Authorization for Medical Care

Yes

Emergency Contacts (Please list two emergency contacts)

Emergency Contact 1 Name

Emergency Contact 1 Phone

Emergency Contact 1 Relationship

Emergency Contact 2 Name

Emergency Contact 2 Phone

Emergency Contact 2 Relationship

Family Physician

Name

Phone

Date of most recent tetanus toxoid immunization

Do you have health/accident insurance? (select one)

Yes

No

If yes, please indicate policy number, name and address of insurance company:

Policy #

Company Name/Address

Medical History

For the following, select appropriate response and explain as appropriate:

Does your Child have any limiting medical conditions that you or your doctor feel would limit camp participation?

Yes

No

If yes, identify and explain:

Is your Child currently taking medication that may interfere with ability to safely participate in Program? (Please Note: Separate medication forms for both OTC and prescriptions will be sent to all parents/guardians to complete no matter the response here.)

Yes

No

If yes, please indicate the medication and the condition being treated:

Does your Child have a history of allergies or reactions to medications, insect stings, or plants?

Yes

No

If yes, please explain:

Does your Child have a history of food allergies?

Yes

No

If yes, please explain:

Does your Child have a history of, or is currently suffering from a medical condition which we need to be aware of?

Yes

No

If yes, please explain:

Payments, Cancellations, and Refunds

Instructions for payment will be sent in a separate email communication after submitting this registration form.

Both Student and Parent/Guardian understand and agree that any cancellation and request for refund must be submitted in writing by email to outreach@bsu.edu no later than June 1, 2024 by the Parent, Legal Guardian or Personal Representative who signs this registration. Students who are dismissed from the Summer Camp for disciplinary reasons or leave early for any reason are not eligible for refund.

The Indiana Academy reserves the right to modify, postpone or cancel the Summer Camp because of low enrollment, health, safety or other issues including, but not limited to, acts of God, acts or omissions of government authority, compliance with government regulations or any other cause or event beyond the control of the organization. In the event that the Indiana Academy would postpone or cancel the summer camp, any payments made will be refunded. The Indiana Academy shall not be responsible for any expenses incurred by Parent, Guardian, Student or others, including, without limitation, all expenses for travel to the Summer Camp and any other miscellaneous expenses incurred.

I have read and agree with the Payments, Cancellations, and Refunds

Yes

Authorization for Medical Care

By clicking YES below I grant Ball State University permission to seek medical care for my Child in the event of illness or medical emergency and to release the medical information as needed on this form in pursuit of that medical care. I will assume the financial responsibility for such medical care.

As a parent, or guardian I understand and acknowledge that my failure to disclose relevant information may result in harm to my Child and/or others during this Program. By signing my name I represent and warrant that I have provided all materials and important information to Ball State University pertaining to my Child’s medical, mental and physical condition and that it is accurate and complete. I agree to notify Ball State University of any changes in my Child’s mental, physical or medical condition prior to my Child’s participation in the scheduled Program. By revealing or disclosing the above medical information I acknowledge that it will not be used by Ball State University personnel or employees to determine my Child’s ability to participate safely in activities. I understand that, if my Child chooses to participate in activities, he/she does so voluntarily and of his/her own accord and the final decision regarding participation is solely the responsibility of myself and my Child.

I have read and agree with the Authorization for Medical Care

Yes

Media, Photo, Video, and Liability Release

In consideration for my Child’s participation in the above captioned event, I, the undersigned parent/guardian of the Child named above, hereby grant to Ball State University, its Board of Trustees, Administration, Faculty, Staff, Students, and all other officers, directors, employees and agents (“University”) the right to reproduce, use, exhibit, display, broadcast, distribute, exploit, 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 the Indiana Academy and University business, the activities of, or for promoting, publicizing or explaining Indiana Academy and 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 Indiana Academy and 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 Indiana Academy and 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, on behalf of my Child, furthermore release, indemnify and hold harmless Ball State University from and against any and all liability, actions, debts, claims and demands of every kind whatsoever, specifically including, but not limited to, any claim for negligence or negligent acts or omissions and any present or future claim, loss or liability for injury to person or property that my child may suffer, for which my child may be liable to any other person, or that may or does arise out of the use of the Materials.

This RELEASE contains the entire agreement between the parties and the terms of this RELEASE are contractual and not a mere recital. The information I have provided is disclosed accurately and truthfully. I have been given ample time to read this document and I understand and agree to all of its terms and conditions. I acknowledge that I am checking YES to these terms freely and voluntarily. My agreement to these terms is intended to bind not only myself but also my successors, heirs, representatives, administrators, and assigns.

I have read and agree with the Media, Photo, Video, and Liability Release

Yes

Student Code of Conduct Statement and Disciplinary Procedures

Each program participant has a reasonable expectation to enjoy a positive program experience. Therefore, the misbehavior of one participant, or a group of participants, should not be permitted to impact negatively on the program experience of others. Most programs are short in duration, so prompt action is required when problems occur. Parents and participants should be aware of the disciplinary policy.

First Offense: Participants failing to adhere to program rules, or exhibiting behavior clearly intended to annoy or endanger other participants, will be formally warned by a Program Counselor and informed that subsequent misbehavior will result in formal counseling by the Program Director.

Second Offense: Subsequent misconduct will result in counseling by the Program Director and a warning that further misconduct will result in removal from Program. At this point, the Program Director will contact the parent or guardian to advise him/her of the situation and the possible need for picking the child up from camp if there is further misconduct.

Third Offense: Any further inappropriate behavior will result in expulsion from Program.

NOTE: BALL STATE UNIVERSITY EXPECTS EACH PARTICIPANT TO HAVE A SUCCESSFUL PROGRAM EXPERIENCE. ANY OF THE STEPS OUTLINED ABOVE MAY BE OMITTED OR REPEATED AT THE DISCRETION OF PROGRAM STAFF. PARTICIPANTS DISMISSED FROM PROGRAM FOR DISCIPLINARY REASONS WILL NOT RECEIVE A REFUND OF ANY FEES PAID TO ATTEND PROGRAM.

It should be understood this procedure is intended to provide a reasonable and consistent method for dealing with the type of behavior that can be disruptive to a program, but is not so egregious as to warrant immediate dismissal from the program. It in no way precludes immediate dismissal from the program for more serious disciplinary problems or violations of campus or program regulations.

A serious disciplinary problem is defined as one in which the program staff determines that a participant is engaging in inappropriate behavior that includes, but is not limited to the following: actions which put the participant, other participants, or program staff member’s safety in jeopardy; physical, emotional, or electronic harassment/harm against self, program staff or fellow program participants; inflicting physical or emotional harm on self or others, vandalism or destruction of University property; theft of University property or the property of another participant; consistently disrupting the program; possession of alcohol, drugs, or weapons; fighting; sexual harassment; or behavior that is serious enough to warrant a third offense.

By clicking YES below I understand the disciplinary procedures described above. I understand failure of my Child named above to demonstrate proper conduct during camp may result in early dismissal from the program without any refund of fees paid to attend. I pledge to have my Child abide by all program rules and to exercise good behavior and proper respect for others.

I have read and agree with the Student Code of Conduct Statement and Disciplinary Procedures

Yes

Agreement to the Terms of this Release

As the parent/guardian of the student, I certify that I am at least 18 years old and have read and understand the terms of this Release. I understand that by signing this Release I am relinquishing substantial legal rights, including the possibility of recovery for injury, whether the injury results from the inherent risks of the Program or the ordinary negligence of the University, its Board of Trustees, officers, employees, agents, contractors, or volunteers. I am signing this Release, after having carefully read the same, of my own free will, and by doing so, fully intend to release the University, its Board of Trustees, officers, employees, agents, and volunteers from liability or loss due to the inherent risks of the Program or the negligence of the University, its Board of Trustees, officers, employees, agents, contractors, or volunteers.

I have read and agree with the Agreement to the Terms of this Release

Yes

Parent/Guardian Signature and Date

Student Signature and Date