Summer 2017 Application Package APPLICATION DEADLINE May 26, 2017 Please complete all sections. Incomplete forms cannot be processed. Send pages 1-5, along with evidence of gifted identification and/or the completed Supplemental Application Survey (if applying for the first time), to launch@wlu.ca. Camper Information Last Name: First Name: Male Female Number and Street Address: City, Province: Postal Code: School and School Board: Grade (as of September 2017): Birth Date (mm/dd/yyyy): T-shirt size: Youth Small Youth Medium Youth Large Adult Small Adult Medium Adult Large Parent/Guardian Information Name: Home Phone Number: Work Phone Number: Cell Phone Number: E-mail: Address (if different from Camper): Emergency Contact (if Parent/Guardian unavailable): Relationship to Camper: Phone: Names of ALL persons, including parents, who have permission to drop-off or pick-up your child: *** MANDATORY *** How did you hear about LAUNCH camp?
CAMPER S FULL NAME: Supervision after camp 4:30-5:15 p.m. (Please note that there is NO supervision prior to camp until 15 minutes before camp) Circle all the days below that you would like pre-arranged after camp care at the cost of $5 per day. Please note that refunds will not be given for missed or cancelled days. Monday July 13 Tuesday July 14 Wednesday July 15 Thursday July 16 Friday July 17 After Camp Supervision ($5/day) # days x $ 5 = $ REGISTRATION FEE $ 290 REGISTRATION FEE TOTAL $ Method of Payment *** Payments will not be processed until after May 26, 2017 so please ensure that the credit card that you provide does not expire before then. *** Visa/Mastercard #: (circle or underline) Expiry Date: (mm/yy) Name on Card: I acknowledge that I have provided my credit card information for billing purposes. I fully understand that the camp fee(s) on this form will be billed to my credit card after May 26, 2017. Signature: Date: Cash Cheque Payable to: Wilfrid Laurier University I acknowledge that payment by cash or cheque must be received by the Faculty of Education before the registration can be processed. I will ensure that a copy of this form is enclosed with my payment. LAUNCH is limited to the first 15 qualified, paid campers. Please note: We recognize that this document may not include best practices in accessibility. We are working to create a more accessible version of this material. If you do require an accessible version, please connect with launch@wlu.ca who will work with you to ensure you receive the information in a format that works for you. 2
STANDARD RELEASE FORM Please note that LAUNCH is a subsidiary of LEAP and subject to the same regulations. * Please fill out form completely and email with your registration. * LAUNCH Camp s Privacy Statement: Personal information from individuals involved in the LAUNCH camps (including name, address, phone number, and e- mail address) is collected and printed, but will not be shared with any other outside organization. Personal information is for use by Wilfrid Laurier University as a means of communication for all events pertaining to the LAUNCH camp. WLU must adhere to guidelines pursuant to Municipal Freedom of Information and Protection of Privacy Act specifically regarding the protection of personal information for those individuals under the age of 18 years. Parents/guardians of those under the age of 18 are to be informed of the potential uses of their child s personal information. During the LAUNCH Camps, campers will be involved in a variety of LAUNCH -related activities and events. There are situations where personal information might be used for promotional and/or marketing reasons, as listed below. You will be notified of activities that do not fall under the following descriptors as, or if, they develop. PART A: i) Specific information from the Registration Form (name, phone number and e-mail contact information) may be provided to the staff for communication purposes, as required. ii) Names, photographs, videos and/or auditory recordings may be used for newsletters, displays, individual camp photo CDs if applicable, and local television, radio and newspaper media for informational and/or marketing related purposes. iii) Emergency and Medical Personnel Names, addresses, telephone numbers, and birthdates, as well as the names, addresses and home/work telephone numbers of their parents/guardians, are shared with medical and/or other emergency personnel when circumstances demand it. PART B: Internet & Website use of photographs and voice recordings Photographs and voice recordings may be used on our LAUNCH website for camp related activities. Names and full faces are not used on the Internet unless there is written consent from every member contained in the photo. PART C: I have read LAUNCH s Standard Release Form and give permission for the LAUNCH Camp to use my child s personal information, based upon the preceding conditions outlined in Part A and Part B of this form. *** If you have any objections with any of the above, please indicate your concerns in the comments section below. *** Name of Youth: Name of Parent/Guardian: Phone Number: Date: Signature of Parent/Guardian: Comments: 3
CAMPER EXPECTATIONS FOR ALL CAMPERS: Please read the following, sign below and submit with registration form. Our highest priority is the safety of all of our campers. Wilfrid Laurier University s LAUNCH has a non-tolerance policy for misconduct which puts any camper, camp personnel or university property at risk. Within the camp environment, students are expected to act in ways that respect the needs, feelings, heritage and rights of all. All campers are expected to act in a manner consistent with the standards of behaviour outlined below: 1. Definitions of Bullying Bullying means aggressive and typically repeated behaviour by a pupil where the behaviour is intended by the camper to have the effect of: 1.1 causing harm, fear or distress to another individual, including physical, psychological, social or academic harm, harm to the individual s reputation or harm to the individual s property, or 1.2 creating a negative environment at camp for another individual 1.3 For the purposes of the definition, bullying behaviour includes the use of any physical, verbal, electronic or written means. 2. Means and Forms of Bullying Bullying is a dynamic of unhealthy interaction that can take the following means and forms: 2.1 Physical bullying includes but is not limited to behaviour such as hitting, kicking, shoving, spitting, beating up, stealing or damaging property 2.2 Verbal bullying includes but is not limited to behaviour such as name calling, mocking, hurtful teasing, using abusive, vulgar or other inappropriate language, humiliating or threatening someone, racist comments, or sexual harassment. 2.3 Electronic or Cyber- bullying includes but is not limited to harassing or threatening other users, using abusive, vulgar or other inappropriate language, vandalism of accounts or systems, or accessing adult-only sites. In addition to bullying, any persistent behaviour that interferes with the learning of other students will not be tolerated. LAUNCH personnel will deem what is appropriate behaviour and computer use, and their decisions will be final. Violations may lead to parental contact and possible removal from camp without monetary reimbursement. LAUNCH may terminate a camper s participation if his/her willful misconduct or actions interfere with the operation of the program. WLU has the right to hold campers or parents financially responsible for any damages or loss of property incurred at their program site due to a camper s willful misconduct or irresponsible actions. Disruptive behaviour will be handled through the following process: 1. The misbehaving camper will be spoken to by the camp leader, who will outline why the camper s actions were inappropriate and to remind them what is expected of campers at LAUNCH. The camp leader may request the involvement of the camp coordinator or program coordinator. 2. If this situation needs to be repeated more than once in a single day, the camp leader will write an incident report which will be given to the parent/ guardian to read and sign at the end of the camp day. The report will be sent to the LAUNCH office. 3. If a camper receives three written behaviour-related incident reports, the camper will be removed from camp with no monetary reimbursement, effective at the end of the day of the third report or immediately if necessary. I hereby acknowledge that I have read and fully understand the terms, policies and conditions set out herein. Parent/Guardian Signature: Date Signed: 4
MEDICAL FORM * Medication must be authorized by the Camp leader or designate prior to administering. * Please Note: It is understood that the preferred practice is that all medication be administered by the parent/guardian at home during non-camp hours. If a medication must be administered during camp hours, it is suggested that the camper s physician be consulted to prescribe an alternative medication that does not require administration during camp hours, if possible. Please complete the Administration of Medication Authorization Section of this form for any prescribed medications to be taken while at LAUNCH Camp. Over-the-counter medications will not be dispensed to any camper, unless prescribed by a physician. For all campers, a signature is required on the 2 nd page of this form. TO BE COMPLETED BY PARENT/GUARDIAN Name of Camper: Birth Date (mm/dd/yyyy): Full Health Card Number: Number and Street Address: City, Province: Postal Code: Name of Physician: Address of Physician: Phone number of Physician: Are there any specific medical concerns/allergies of which we should be aware? No Yes If yes, please describe. Please list all medications being routinely taken (including over-the-counter or non-prescription drugs), as well as their dosage and frequency. Medications sent with your child must be in the original bottle or package. Please indicate if there is anything important that LAUNCH personnel should know with regard to your child s social, emotional, interpersonal, or behavioural needs. Feel free to include any information about supports at school. 5
ADMINISTRATION OF MEDICATION AUTHORIZATION if applicable Medication may be self-administered by the camper. (Provide details below.) Medication must be administered by LAUNCH Camp personnel: I, administration of (name of medication) for (reason) to my child authorize the by LAUNCH leader or designate. Date prescription started / / Date medicine started at Camp / / Times of Administration: 1. 2. Dosage: Has this medication been prescribed by a physician? Yes No Is refrigeration required? Yes No Prescribing physician s name: Phone number: Special Instructions be specific (e.g., Must be taken with food, Administer epi-pen to thigh after exposure to nuts and difficulty breathing and/or swelling of the lips/tongue/throat, then call 911, etc.): Possible Side Effects: FOR ALL CAMPERS: Please read the following, sign below and submit 2 page medical form with registration form. 1. In the event of an emergency and/or special medical treatment, parent/guardian(s) will be notified immediately. If the parent/guardian(s) cannot be reached, permission is hereby given to LAUNCH Camp personnel to take whatever steps they deem necessary to ensure the safety and health of my child. This also gives LAUNCH Camp personnel permission to get in touch with the emergency contact and/or my child s physician. 2. As the parent/guardian of the above-named camper, I request and authorize LAUNCH camp personnel to administer prescribed medication referred to in the accompanying Medical Form, using the procedures outlined above. Also, I acknowledge LAUNCH Camp personnel are not medically trained to administer medications. 3. I understand and accept that if questions arise about the administration of medication, the camp leader/designate will contact the parent/guardian to come to camp and administer the medication. Therefore, it is the responsibility of the parent/guardian to ensure that all medication is in the original container and all information regarding dispensing is clearly marked. 4. No more than the daily dose(s) of any prescribed medication is to be sent to LAUNCH Camp at any time unless other arrangements are made with the Camp Co-ordinator prior to the start date. 5. I also understand and accept that if problems arise with the administration of the medication (i.e., refusal by the camper to take the medication, complaints of side effects, possible allergic reactions, etc.), the camp will immediately discontinue further doses and inform the parent/guardian. Any changes made to the administration regimen must be outlined on a new medical form. 6. I understand and accept that the camp leader/designate can reserve the right to refuse to administer treatment to the camper if the necessary information is not provided by the parent/guardian. 7. I hereby release Wilfrid Laurier University, its employees, agents and volunteers from all manner of actions, causes of actions, suits, losses, damages or injuries, however caused, arising out of the administration or failure to administer medication as provided herein. I do also hereby indemnify Wilfrid Laurier University, its employees, agents and volunteers for any losses or damages sustained by them as a result of such actions or proceedings being commenced against them by myself or the camper or any other parent or guardian of said camper. 8. I hereby acknowledge that I have read and fully understand the terms, policies and conditions set out herein. Parent/Guardian Signature: Date Signed: 6
LAUNCH Summer 2017 POLICIES & CONDITIONS * Please keep pages 7 and 8 for future reference do not return them with the registration form. * Eligibility: LAUNCH is open to campers in Grade 4 to Grade 8 (as of September 2017) who have been identified as gifted by psychological assessment and/or eligible for gifted services by IPRC recommendation. Evidence of gifted identification (psychological assessment or IPRC) MUST be attached to registration form. If such documentation is not available, families can submit a completed Supplemental Application Survey (three pages) found on the LAUNCH website. If documentation is not provided or is insufficient, parents will be notified that their application cannot be accepted until it is complete. Any questions regarding eligibility can be directed to Dr. Colleen Willard-Holt at cwh@wlu.ca. Camp Hours and Location: Drop off begins at 8:15 a.m. Camp begins at 8:30 a.m., with pick up at 4:30. There is a supervised lunch period. All camps are held in the Bricker Academic Building, WLU, home of the Faculty of Education. Parental Expectations: We ask that all parents/guardians please respect the hours of operation for our camp. For safety reasons, do not drop off campers before 8:15 a.m. and ensure that campers are picked up by 4:30. You will be allowed a 10 minute grace period after which you will be charged $5 for every ten minutes that you are late. If not picked up by the end of the grace period, your camper will be taken to the LEAP Office (BA311) to await your arrival. Pre-arranged Late Pick-Up: Arrangements can be made in advance for supervision of campers after camp from 4:30-5:15 p.m. for an additional fee of $40 per week or $8 per day. Please indicate your request for late pickup on the registration form. Refunds will not be given for missed or cancelled days. Peanuts/nuts: LAUNCH strives to create a nut-free environment, but cannot guarantee it. It is asked that all food sent to camp is nut-free. Please make sure to fill out the medical form if your child has an anaphylactic allergy to nuts or any other food. Cancellations: All cancellations must be received in writing via email to LAUNCH@wlu.ca no later than May 26, 2017 for full refund. After this date, a $25.00 administration fee will be charged. Parents will be notified as soon as possible after registration closes if the camp is full. A full refund will be given in such circumstance. 7
Pick-up Procedure: Only the person(s) listed on the registration form are allowed to pick up that child. In the future, let us know of any changes to this information. Please note that all persons picking up a camper, including parents, will be asked for photo ID every day before a camper is released into their care. Safety and Liability: Wilfrid Laurier University, its employees, LAUNCH, agents and volunteers shall not be held responsible for any damage, loss or claim of injury resulting from events beyond its control, including acts of God, strikes, or sickness. Wilfrid Laurier University cannot be held responsible for events resulting from inappropriate or irresponsible camper behaviour. Camper Expectations: Wilfrid Laurier University s LAUNCH has a non-tolerance policy for misconduct which puts any camper or camp personnel at risk. This includes, but is not limited to, inappropriate actions towards another person and improper computer use which violates LAUNCH s computer policy. The following are examples of improper computer use: - harassing or threatening other users - using abusive, vulgar and other inappropriate language - vandalism of accounts or systems - accessing adult-only sites LAUNCH personnel will deem what is appropriate behaviour and computer use, and their decisions will be final. Violations may lead to parental contact and possible removal from camp without monetary reimbursement. LAUNCH may terminate a camper s participation if his/her willful misconduct or actions interfere with the operation of the program. WLU has the right to hold campers or parents financially responsible for any damages or loss of property incurred at their program site due to a camper s willful misconduct or irresponsible actions. Camp Shirt: Each LAUNCH camper will receive a LEAP t-shirt on the first day of camp. This shirt must be worn every day to identify their involvement on a busy university campus. Extra shirts can be purchased at a cost of $10 per shirt. Further details: Close to the camp date, you will receive an e-mail with final details such as drop-off/pick-up locations and procedures, maps, and parking instructions. If you have questions before that time, please email LAUNCH at LAUNCH@wlu.ca or call LAUNCH at 519.884.0710, ext. 3173. 8