Ebenezer's Explorers Day Camp Fall2023

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University of Montevallo
75 College Drive
Montevallo, AL 35115
jshumate@montevallo.edu
Telephone: (205) 665-6195

Ebenezer's Explorers Day Camp Registration

Student Information
Please complete the below information for the student who will be participating in Ebenezer's Explorers Day Camp.

Last Name:

First Name:

Middle Initial:

Student's Sex:

Permanent Address:

City:

State:

Zip:

Cell Phone Number:

Date of Birth:

Age:

Current School:

Current Grade:

Name of Person Completing Form:

Relationship to Student:

E-Mail Address:

Cell Phone Number:

Medical Information
Does the student have any of the following? (If yes, please describe.)
***Please note: Our staff cannot administer any medications, prescription or non-prescription to participants. This includes over-the-counter medicines such as Advil or Tylenol for minor aches or pains.

Drug allergies:

Frequent headaches:

Food allergies:

Dizziness or seizures:

Allergies to insect bites:

Heart condition:

Special dietary needs:

Other health conditions:

Asthma:

Limitations of activities:

Diabetes:

Current medications:

Medical Emergency Contact Information
In case of a medical emergency, please list a primary and secondary contact below.

Primary Contact Name:

Relationship to Student:

Daytime Phone Number:

Cell Phone Number:

Secondary Contact Name:

Relationship to Student:

Daytime Phone Number:

Cell Phone Number:

Ebenezer's Explorers Day Camp Consent Form
The following consent information is required for participation in Ebenezer's Explorers Day Camp provided by the University of Montevallo. This must be completed by a parent or guardian if the participant is under the age of 19.

Student Name:

In the event of accident or sickness, I expect to be contacted as soon as practical, but consent to allow the above-named minor to be provided with emergency medical care and treatment offered by medical or paramedical personnel and authorized transportation for such purpose, should the above be deemed reasonable and prudent. I further understand and agree that any cost associated with such medical care shall be my financial responsibility.

I further promise not to sue, and agree to indemnify and hold harmless UM and its Board, officers, agents, servants, and employees for any damage to person or property or any harm, mental or physical, should any occur, during the course of, as a result of, or in any way related to my participation in the above-named event at the University of Montevallo.

This waiver and release also extends to my minor child’s participation in the above-named event at the University of Montevallo in its entirety.

I am 19 or older, have read this release, understand, and consent to all its terms. By typing my name in the blank below, I voluntarily sign it with full knowledge of its significance.

Signature of Student (or Parent/Guardian if Student is under the age of 19):

Today's Date:

Policy Agreement
The following policy agreement is required for participation in Ebenezer's Explorers Day Camp provided by the University of Montevallo. This must be completed by a parent or guardian AND the participant.

Student Name:

The signatures below verify that both the Parent/Guardian and Participant have read and agree to abide by all University of Montevallo (UM) Camp/Workshop policies described below. I understand that UM authorities have the right to expel participants for violations of the University Camp/Workshop policies as described below and that under such circumstances no refunds will be issued.

Dress Code

Clothing should be appropriate for a K-12 school-related function. This includes clothing length, body coverage, themes, etc.
Clothing exhibiting inappropriate graphics, foul language, or adult themes is prohibited. The UM camp/workshop director(s) will determine if clothing could be considered inappropriate or offensive.

Cell Phones

Students are permitted to bring cell phones in order to remain in contact with friends and family prior to and after instruction and during breaks.
Cell phones will remain off during instruction time.
Camp/workshop directors and counselors are not responsible for loss or damage caused to cell phones.

Prohibited Materials

It is expected that all camp/workshop participants behave as if they were on their K-12 school campus. Simply put, if a behavior is prohibited on a typical K-12 school campus, it is not allowed at a camp/workshop on the UM campus.
Weapons of any kind, including firearms, knives of any type and blade length, throwing stars, nun chucks, batons, or toys resembling such items are prohibited. As this campus is a "gun free zone," it may be necessary to involve campus police should weapons be discovered.
Flames of any kind, including cigarette lighters, incense, or candles are prohibited.
The camp/workshop director(s) will determine if personal items could be considered inappropriate or dangerous. Dangerous or inappropriate personal items will be confiscated by the camp/workshop director(s) or campus police if necessary, held for the duration of the camp/workshop, and returned to parents upon check-out as appropriate.

Illegal Substances

Possession or use of cigarettes and any other form of tobacco is prohibited and will result in dismissal from the camp/workshop.
Possession or use of alcohol in any form is prohibited at the camp/workshop and will result in dismissal from the camp/workshop and contact with campus police.
Possession of or the use of drugs, including marijuana and prescription drugs that are not prescribed to the user, are prohibited at the camp/workshop and will result in dismissal from the camp/workshop and contact with campus police.
Prescribed medication for allergies or special medical problems should be listed on the medical form. It is the student's responsibility to take the prescribed dosage. Camp/workshop participants should not share prescription or non-prescription medications with other participants.

Interactions with Others

For the safety of all involved, camp/workshop participants are prohibited from socializing with University of Montevallo students or those participating in other camps, workshops, or campus activities.
At no time will camp/workshop participants travel between activities or be left alone in the dormitory, dining hall, or academic facilities without the supervision of a camp/workshop director or counselor. All camp/workshop activities are intended to be group activities.
Camp/workshop participants will refrain from physical contact with other participants, including personal displays of affection, wresting, horseplay, fighting, etc.
There will be no running, wrestling, horseplay, athletic activities, pranking, etc., in the dormitory, dining hall, or academic facilities.
Inappropriate behavior will result in a warning, followed by parent contact, and perhaps dismissal from the camp/workshop and/or contact with campus police as appropriate.
Bullying of any type is prohibited by participants and will result in immediate dismissal from the camp/workshop.
For the safety of all our participants, unannounced visitors, regardless of their relationship to participants, will not be allowed to enter dormitories or academic facilities in which camp/workshop activities are being held.

Other

If a student must leave Ebenezer's Explorers Day Camp early for any reason (including an emergency), the student MUST be checked out by a parent or legal guardian as indicated on their emergency contact list.

I agree to the terms above and understand that the University of Montevallo will not be responsible for lost, stolen, or damaged personal property. I understand by typing my name below I am considering this my signature and legally binding.

Signature of Student:

Today's Date:

Signature of Parent or Guardian:

Today's Date:

Photo/Video Release
The following photo/video release information is optional. This must be completed by a parent or guardian if the participant is under the age of 19.

I hereby grant permission to the University of Montevallo to use photographs and/or video of me (or my child if under 19 years old) taken during Ebenezer's Explorers Day Camp in publications, news releases, online, and in other communications related to the mission of the University and it’s Environmental Education Program. I understand by typing my name below I am 1) 19 or older 2) the person described above 3) considering this my signature and legally binding.

Signature of Student (or Parent/Guardian if Student is under the age of 19):

Today's Date:

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