Summer Driver Education 2022 Application

Alcohol or drug use? *

Yes No

If yes, please explain

Hepatitis? *

Yes No

If yes, please explain

Chicken Pox? *

Yes No

If yes, please explain

Immune disorder *

Yes No

If yes, please explain

Measles (rubella) *

Yes No

If yes, please explain

Meningitis or encepalitis? *

Yes No

If yes, please explain

Mumps *

Yes No

If yes, please explain

Scarlet fever? *

Yes No

If yes, please explain

Strep throat? *

Yes No

If yes, please explain

Tuberculosis or exposure to it? *

Yes No

If yes, please explain

Whooping cough (Pertussis)? *

Yes No

If yes, please explain

Any syndrome or other illness / condition requiring medical care? *

Yes No

If yes, please explain

Any surgeries? *

Yes No

If yes, please explain

Is the camper now under the care of a physician for any reason? *

Yes No

If yes, please explain

Date of last tentanus? *

Month Day Year

Camper Height *

Camper Weight *

If your child has insurance, please send an electronic copy of the front and back of your insurance card to hannah.torres@tsd.state.tx.us.

Insurance Type *

Medicaid private/group insurance Self-insured None

Front of Insurance Card

File Types Accepted: pdf, jpg, jpeg, png

Back of Insurance Card

File Types Accepted: pdf, jpg, jpeg, png

Does the camper have allergies to any medications? *

Yes No

If yes, please explain

Does the camper have allergies to any foods? *

Yes No

If yes, please explain

Does the camper have any other allergies? *

Yes No

If yes, please explain

Are there any other over-the-counter medications the camper cannot take? *

Yes No

If yes, please explain

Does the camper take any over-the-counter medications? *

Yes No

If yes, please explain

Does the camper take any prescription medications? *

Yes No

If yes, please explain

To the child's parents/guardian, the following is simply the precautions we want to take in case of the child has an opportunity to participate in water activity or field trip. Not all camps or programs will have water activities. Before the child can join any water activity:

2. the TSD Health Center must give permission; and

3. your child's swimming abilities will be tested by a Lifeguard and your child's swimming level will be identified - either "deep-water swimmer," "shallow-water swimmer" or "non-swimmer"

By selecting yes to any of the fields below, you are giving your permission for them to participate in said activity pending the TSD Health Center and Lifeguard clearance.

I understand the terms of the statement above. *

Yes No

Wading Activities at TSD and Other Swimming Areas - Campers will occasionally be allowed to wade (walk in water depth of 18 inches or less) on field-trips to creeks, ponds, springs and other locations that have shallow areas in which wading is permitted. Wading may also take place in rubber wading pools on or off the TSD campus.

I give my permission for the wading activities as described above. *

Yes No

Recreational Swimming Activities at TSD or Off-Campus Pools - Recreational swimming activities take place in the TSD Swim Center and at pools off-campus. Campers are allowed to go into the pool as deep as their swim level permits and swim or play. A Lifeguard(s) supervise recreational swimming. *

Yes No

Recreational Activities in Natural Bodies of Water - Summer Camps & Programs may conduct recreational activities at lakes, springs or other natural bodies of water. Summer Camps & Programs will ensure that Lifeguards and other necessary supervision is provided for these activities. *

Yes No

Recreational Activities in Natural Bodies of Water - Summer Camps & Programs may conduct recreational activities at lakes, springs or other natural bodies of water. Summer Camps & Programs will ensure that Lifeguards and other necessary supervision is provided for these activities. *

Yes No

Off-Campus field-trips - The child may have the opportunity to go on field-trips throughout Austin or Central Texas. The activity may involve hiking, playing outdoor games, roller skating, eating at restaurants, attending museums, playing video games in an arcade, or other activities. An appropriate number of Summer Camps & Programs staff will act as chaperones and supervisors on the field-trip. *

Yes No

Field-trip to Fiesta Texas-Six Flags - Your child may have the opportunity to go on a field-trip to Fiesta Texas-Six Flags. The activity may involve going swimming in the large park pool that has lifeguards; riding roller coasters, age & height appropriate rides at the park; playing video games in the arcade. An appropriate number of Summer Camps & Programs staff will act as chaperones on the field-trip. *

Yes No

Field-trip to Schlitterbahn or Splashtown Water Parks - The child may have the opportunity to go on a field-trip to Schlitterbahn Water Park in New Braunfels or Splashtown Water Park in San Antonio. This activity may involve swimming, tubing, going down water slides. Schlitterbahn and Splashtown provide lifeguards for all activities. An appropriate number of Summer Camps & Programs staff will act as chaperones on the field-trip. *

Yes No

Are there any activities in which the camper cannot participate for any religious, health or other reasons? Please explain if so.

I give my permission to the Summer Camps & Programs to photograph, audiotape, and/or video tape the child for news media coverage, electronic media (including TSD and or SOC/ESC 11 Resource Websites), school brochures, publicity related to participation in co-curricular or extracurricular activities. I understand these will represent the child favorably. *

Yes No

I verify that I am the parent/guardian of the afore-named camper (or self if 18 or over) *

Yes, I am the parent or guardian No, I am not the parent/guardian or the individual wishing to attend Yes, I am the registrant wishing to attend and am between 18-22 years old

The information I provided on the "Summer Camps & Programs" application is true and complete to the best of my knowledge. *

Yes No

The medical information is true and complete to the best of my knowledge. I give permission for the child or self, to be treated by the TSD physician and Health Center staff in case of illness and/or to be transported to and receive medical treatment in a hospital emergency department or other health care facility if determined to be necessary by Summer Camps & Programs staff. I will be notified of any treatment by a physician. I understand emergency medical expenses incurred will be my responsibility. *

Yes No

The child has my permission to be transported in a TSD vehicle for the camps/program *

Yes No

I understand that I am required to make full payment to TSD by 4/1/2022, pending my child's camp confirmation letter from the SCP team. *

Yes No

I understand that there will be no refunds after 4/30/2022 if the cancellation is made by me. *

Yes No

I understand that a parent, guardian or emergency contact must be able to be reached at all times during Summer Camps & Programs *

Yes No

Full name of family representative (self or parent/guardian) *

Signature (self if age 18-22 or parent/guardian) *

Clear

Date *

Month Day Year

Thank you for completing the application for our summer Driver Education program.

Press "Submit" if you are ready to send the application.

Press the "Back" button if you need to review your information or make changes.

Camper/Participant Information

School Information

Information About Parent/Guardian/Other

Information About Second Parent / Guardian / Other (Optional)

Emergency Contact Information

Emergency Contact #1

Emergency Contact #2

Health History

Concussion / Head Injury

Medical Devices

Immunizations

Insurance

Allergies

Activity Permissions