2023 CSI CAMP - ALLENDALE

2023 CSI CAMP - ALLENDALE
Participant's Name*

First NameLast Name
Age*
Parent or Guardian Name:*

First NameLast Name
Parent or Guardian Email*
example@example.com
Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
T-shirt Size*

Program:

USC Salkehatchie CSI CAMP

Location and Dates:

USC Salkehatchie

Allendale Campus - 465 JAMES BRANDT BLVD., ALLENDALE, SC 29810

June 13 - 14, 2023
Participant's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Grade*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number to Reach Participant:*
Please enter a valid phone number.Format: (000) 000-0000.
Please answer these questions about your child/the participant:
Does your child/participant have any allergies (including food) or a special diet we should know about prior to participating in the program and prior to emergency treatment, if necessary? If yes, please explain.*
Does your child/participant have any chronic conditions/illness that we should know about prior to emergency treatment? If yes, please explain.*
Does your child/participant have any disability/special needs (visual, hearing, physical, psychological, unable to climb stairs without assistance) which requires special attention or special accommodation? If yes, please explain.*

Program:

USC Salkehatchie CSI Camp

Location and Dates:

USC Salkehatchie

Allendale Campus - 465 JAMES BRANDT BLVD., ALLENDALE, SC 29810

June 13 - 14, 2023
Consent and Waiver

In consideration of my child, the participant, being permitted to participate in the above camp, I, and on behalf of my child, agree and understand that:
- My child will abide by all the rules, guidelines, regulations, and code of conduct of USC and/or host/site location requirements;
- My child will be in a class with the instructors. I recognize this class is unique in that students are allowed the freedom to advance their studies without direct one-on-one supervision;
- My child may be asked to leave the class if I or my child do not abide by the rules, regulations, and code of conduct of USC and/or the host site location requirements;
- The instructor has sole authority to make decisions regarding my child's continued participation if my child's conduct or the circumstances warrant removal, dismissal,expulsion, discipline, or other action, including return to home base or permanent residence at my sole expense, without notice to me, and the forfeiture of funds, deposits, or fees;
- My child's participation in this class is voluntary;
- I recognize that my child's participation in the class carries with it risks, including, but not limited to, criminal acts, injuries, illness, death, property losses, and other damages,that cannot be eliminated regardless of the care taken;
- I have investigated the risks involved in this class and I freely assume the risks and consent to my child's participation;
I further declare that my child is fit and capable of participating in the class. Further, I, individually, and on behalf of my child, agree to:
- Complete and timely submit all necessary forms and paperwork;
- Timely pay any necessary deposits or fees;
- Confirm that my child has medical and health insurance coverage while participating in the class;
- Give the class staff the permission, in case of accident or injury, to administer standard first aid/or to arrange for transportation to a medical facility;
- Be solely and completely liable for any expenses incurred on my or my child's behalf, including, but not limited to, medical or health care expenses;
- Immediately advise the USC staff and/or host site administrators of any situation or condition that may be a potential hazard or risk of which I am aware, or of which I become aware.
I have read and agree to the terms outlined above
Parent / Guardian Name*

First NameLast Name
Signature*
Date

MonthDayYear
Date

Program:

USC Salkehatchie CSI Camp

Location and Dates:

USC Salkehatchie

Allendale Campus - 465 JAMES BRANDT BLVD., ALLENDALE, SC 29810

June 13 - 14, 2023
Photo Release

I give USC, its agents, employees, servants, assigns, and successors, without expectation of value, permission to:
1. Record my child’s likeness and appearance on videotape, audiotape, film, photograph, or any other medium; and
2. Use my child's name, likeness, voice, and biographical material in connection with these recordings; and
3. Exhibit, copy or distribute such recording in whole or in part without restrictions or limitation for any educational or promotional purpose or advertisement campaigns which the University of South Carolina, and those acting pursuant to its authority, deem appropriate.
I have read and agree to the terms outlined above
Parent / Guardian Name*

First NameLast Name
Signature*
Date

MonthDayYear
Date

Program:

USC Salkehatchie CSI Camp

Location and Dates:

USC Salkehatchie

Allendale Campus - 465 JAMES BRANDT BLVD., ALLENDALE, SC 29810

June 13 - 14, 2023
Student Release – Pick Up List

I, furthermore, agree that my child may only be released to the following individual(s) during the camp. Parents/Guardians: Please include your names as well as any others authorized to whom to release your child. Please do not ask us to rely on a verbal permission. If your child is riding with another participant, please indicate the driver’s name below.
Name and Relationship of Persons Authorized to Pick Up Participant*
My child MAY NOT be released to the following individuals:
Name(s)/Other Information
Please attach court or legal documents as appropriate for individuals who are not to pick up your child.

Cancelof
Parent / Guardian Name*

First NameLast Name
Signature*
Date

MonthDayYear
Date

Program:

USC Salkehatchie CSI Camp

Location and Dates:

USC Salkehatchie

Allendale Campus - 465 JAMES BRANDT BLVD., ALLENDALE, SC 29810

June 13 - 14, 2023
Waiver and Release of Liability

Further, in consideration for my child being permitted to participate in the class, I, on behalf of my child, and as the natural parent and/or as the legally authorized guardian, do hereby for my child, myself, my family, heirs, personal representatives, and assigns, agree to, and hereby do, release, waive, discharge, hold harmless and indemnify, and forever defend the State of South Carolina, the University of South Carolina, the members of its Board of Trustees, individually and collectively, its officers, employees, servants, agents, representatives, directors, students, volunteers, and anyone acting on behalf of the University of South Carolina, from any and all liability, losses, claims, actions, suits, procedures, demands, rights, and causes of action of whatever nature, in law and equity, for any and all known or unknown, foreseen or unforeseen, bodily or personal injuries, death and permanent injury, illnesses, damage to property, or other losses, and any consequences thereof, including expenses, costs, and attorney's fees, as may be sustained by my child or me, or any person or entity acting on my or my child’s behalf, arising out of, or in any way associated with, my child's participation in the class.

I warrant I am the parent or authorized legal guardian of the participant in the class, and I warrant that I am 18 years of age or older. I have carefully reviewed, and I agree to the terms of this entire document.
I have read and agree to the terms outlined above
Participant's Name*

First NameLast Name
Participant's Signature*
Date*

MonthDayYear
Date
Parent / Guardian Signature*

First NameLast Name
Parent/Guardian Signature (Required)*
Date*

MonthDayYear
Date

Program:

USC Salkehatchie CSI Camp

Location and Dates:

USC Salkehatchie

Allendale Campus - 465 JAMES BRANDT BLVD., ALLENDALE, SC 29810

June 13 - 14, 2023
Emergency Contacts
Emergency Contact #1*

First NameLast Name
Relationship*
Primary Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Work
Please enter a valid phone number.Format: (000) 000-0000.
Cell
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact #2*

First NameLast Name
Relationship*
Primary Number*
Please enter a valid phone number.Format: (000) 000-0000.
Work
Please enter a valid phone number.Format: (000) 000-0000.
Cell
Please enter a valid phone number.Format: (000) 000-0000.

HEALTH AND EMERGENCY INFORMATION FORM
UNIVERSITY OF SOUTH CAROLINA
USC Salkehatchie

Allendale Campus - 465 JAMES BRANDT BLVD., ALLENDALE, SC 29810

June 13 - 14, 2023
Participant's Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Grade*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Blood Type
Health/Special Needs Information
Do you have any allergies that we should know about prior to emergency treatment?*
Do you have any chronic conditions/illness that we should know about prior to emergency treatment?*
Do you have any disability/special needs (visual, hearing, physical, psychological, unable to climb stairs without assistance) which requires special attention or special accommodation? If yes, please explain.*
Please list any medications you are currently taking. Include prescription name, dosage, doctor and special instructions.*
Medical Authorization
The University of South Carolina is also authorized to provide or to arrange for any medical treatment my child may need during the course of this program. I understand and agree to be responsible for any and all costs associated with such services.

In such an event of illness or injury, I wish to be contacted at the following telephone numbers:
Primary Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mobile Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Other Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
In addition to authorizing medical care, I hereby certify that any charges related to the medical care given to my child will be borne by me. The insurance company and policy information that covers my child is as follows:
Insurance Carrier
Policy Holder
Policy Number
I understand the medication prescribed by my physician will be kept in a locked box by the staff while I am participating in the program. It is my responsibility to obtain the medication from the staff and take the medication as directed by the physician.
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Signature*
Date*

MonthDayYear
Date
Participant Name*

First NameLast Name
Participant Signature*
Date*

MonthDayYear
Date

2023 CSI CAMPS

USC Salkehatchie

Allendale Campus - 465 JAMES BRANDT BLVD., ALLENDALE, SC 29810

June 13 - 14, 2023
Participant Name:*

First NameLast Name
Date of Birth*

MonthDayYear
Date
For my child to participate in the described Program, I hereby give consent to receive or give permission for my child to be in possession of the following Prescription Medications, over-the-counter drugs, or health or medical monitoring devices.
Name of Participant’s Personal Physician:*
Physician's Telephone Number*
Physician's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please choose ONLY ONE. Select either Option A or Option B.
OPTION A: No medications/devices are approved: I declare that my child/Participant will not be in possession of any prescription medication, over-the-counter-drugs, nor health or medical monitoring devices, including birth control prescriptions, emergency inhalers (such as for asthma), and emergency injectors for anaphylaxis (such as EpiPen).
I Agree to the terms in OPTION A
Parent/Legal Guardian Initials:
Date

MonthDayYear
Date
OPTION B:For my child to participate in the described program, I hereby give consent to receive or give permission for my child to be in possession of the prescription medications, over-the-counter drugs, or health or medical monitoring devices listed below
I agree to the terms in OPTION B
Parent's / Guardian Name

First NameLast Name
Parent / Guardian Signature
Date

MonthDayYear
Date
Emergency Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Medications or Medical/Health Monitoring Device:
Prescribing Physician's Name
Prescribing Physician's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Dosage Instructions
Potential side effects:
YesNo
For each additional medication, please download the form below and complete for for each medication or device.
Upload the completed additional forms.

Cancelof
Should be Empty:

2023 CSI CAMP - ALLENDALE

Program:

Location and Dates:

Program:

Location and Dates:

Consent and Waiver

Program:

Location and Dates:

Photo Release

Program:

Location and Dates:

Student Release – Pick Up List

Program:

Location and Dates:

Waiver and Release of Liability

Program:

Location and Dates:

Emergency Contacts

HEALTH AND EMERGENCY INFORMATION FORMUNIVERSITY OF SOUTH CAROLINA

HEALTH AND EMERGENCY INFORMATION FORM
UNIVERSITY OF SOUTH CAROLINA