2019 Summer Engineering Technology Program

School Counselor Recommendation Form

The following questions should be answered by the student applicant’s school counselor and turned in by May 31.

Name of student: __________________________________

The student has applied to the Summer Engineering Technology program offered at Florida Atlantic University,

Boca Raton campus Summer 2019.

GPA: _____

Do you recommend this student for the program: Yes ____ No ____

Comments: ___________________________________________________________________________________

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Signature: Date: _________________________________________

PLEASE FAX OR SCAN & EMAIL BY MAY 31 TO:

Florida Atlantic University

Division of Engineering Student Services & Advising

Att.: Evelyn Chang-Cruzpino

777 Glades Road EE 102

Boca Raton, FL 33431

Fax: 561.297.2781

Email: engineering-services@fau.edu

Marketing and Creative Services777 Glades Road, Boca Raton, FL 33431-0991

tel: 561.297.2080 • fax: 561.297.2307 • wplate@fau.edu • www.fau.edu

Boca Raton • Dania Beach • Davie • Fort Lauderdale • Harbor Branch • Jupiter • Treasure CoastAn Equal Opportunity/Equal Access Institution

PHOTO/VIDEO RELEASE FORM

I hereby give permission for the name, likeness and biographical material of the minor child listed below to be used solely for the purposes of Florida Atlantic University-related promotional mate-rial and publications and waive any rights of compensation or ownership thereto.

___ Student ___ Faculty ___ Staff ___ Other

Name of Minor (please print): __________________________________________________________

Address: ____________________________________________________________________________

City: ___________________________________ State:________________ ZIP: ___________________

Name of Parent/Guardian: _____________________________________________________________

Parent/Guardian Signature: ___________________________________ Date: ____________________

Phone number:_____________________________ Email: ___________________________________

OFFICE USE ONLY:M F • W B H A O__________ HR__________ TOP: ______________ BOT: ______________

Participant under 18 years old

Florida Atlantic University Permission and Release of Liability

Pre-collegiate Programs

I, , am the parent and/or legal guardian of , a minor child under the age of 18

years.

I would like to have my child participate in the Summer Engineering Technology Program at Florida Atlantic University (FAU).

In consideration for my child being allowed to participate in this PRE-COLLEGIATE PROGRAM, I the undersigned, acknowledge, appreciate and agree that:

1. I choose to voluntarily allow my child to participate in this PRE-COLLEGIATEPROGRAM. I voluntarily assume full responsibility for any risk of loss,property damage or personal injury, which may be sustained by my child as aresult of his/her participation.

2. I certify that I have adequate health insurance necessary to provide for and pay forany medical costs that may directly or indirectly result from my child’sparticipation in this PRE- COLLEGIATE PROGRAM. I agree to pay for anymedical costs that exceed the limits of my insurance coverage.

________

I do not have medical insurance, but understand the University is not responsible for medical expenses that may directly or indirectly result from my child’s participation in this PRE- COLLEGIATE PROGRAM.

________

I hereby release, waive, and discharge Florida Atlantic University and its Board of Trustees, its officers, agents, employees and representatives from all claims, demands, liabilities, rights and causes of action of whatever kind or nature, that may result from or occur during my child’s participation in the Summer Engineering Technology Program, whether caused by negligence of the UNIVERSITY, its Board of Trustees, officers, agents, employees or representatives or otherwise. I also agree to indemnify and hold harmless the UNIVERSITY for any loss, liability, damage or costs, including court costs and attorney’s fees that may occur as a result of my or my child’s negligent or intentional act or omission while participating in the Summer Engineering Technology Program.

I HAVE CAREFULLY READ THIS PERMISSION AND RELEASE OF LIABILITY AND HAVE HAD SUFFICIENT TIME TO SEEK EXPLANATION OF THE PROVISIONS CONTAINED HEREIN, AND TO DISCUSS ANY QUESTIONS OR CONCERNS I MAY HAVE WITH THE UNIVERSITY OR ITS AFFILIATE. AFTER CAREFUL CONSIDERATION, I SIGN THIS DOCUMENT VOLUNTARILY AND WITHOUT ANY INDUCEMENT.

___________________________________________ _______________ Signature of Parent and/or Legal Guardian Date

___________________________________________ _______________ Signature of Parent and/or Legal Guardian Date

Florida Atlantic University Pre-collegiate Program Health Examination Form

Prime Soccer Enterprise Inc./ Goal to Goal, FAU Soccer Camps

THE FIRST PAGE AND TOP OF SECOND PAGE TO BE COMPLETED BY PARENT OR GUARDIAN. FORM

MUST BE SIGNED AND DATED.

(SEE PARENT’S AUTHORIZATION & PERMISSION TO TREAT)

Participant Name_______________________________________________________________________

Birth Date ___________________ Sex _________ Age _______

Parent or Guardian (or Spouse) ___________________________________________________________

Phone: Day (______)____________ Evening (______)________________ Cell (_____) _______________

Home Address_________________________________________________________________________

Street & Number City State Zip

If not available in an emergency, notify:

1. Name_________________________________________ Relationship to Camper_________________

Home Phone ( )_______________ Work Phone ( )______________ Cell Phone ( )_______________

2. Name_________________________________________ Relationship to Camper_________________

Home Phone ( )_______________ Work Phone ( )______________ Cell Phone ( )_______________

HEALTH HISTORY:

(Check if the participant has had any of the following – giving approximate dates where applicable.)

ALLERGIES:

Ear Infections __________________ Chicken Pox ________________ Hay Fever ____________________

Asthma _________________ Rheumatic Fever ______________ Ivy Poisoning etc. _________________

Seizures __________________ Chest Pain _______________________ Diabetes ___________________

Passing out upon exertion _____________________ Penicillin _________________________________

Insect Stings _______________________ Food _____________________________

(Please provide specific details below.)

Details of Allergies Above (frequency, severity, triggers) and include any additional medication or food

allergies.

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Operations or Serious Injuries

(Dates)_______________________________________________________________________________

Chronic or Recurring Illness_______________________________________________________________

SUGGESTIONS FROM PARENTS:

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IMMUNIZATION RECORD…CAMPERS CANNOT BE ACCEPTED WITHOUT THIS INFORMATION

Required immunizations must determined locally. This is a record of dates of basic immunizations and

most recent booster doses.

DTP Series ___________ booster ___________ Tetanus booster (within the last 10 years) ____________

Polio IPV ____________ booster ______________ MMR ______________________________________

Hepatitis B __________________________ Varicelle (chicken pox)_______________________________

Other state or municipal examinations required if any)_________________________________________

MEDICATIONS THAT MUST BE TAKEN – to be completed and signed by a parent or legal guardian

____ This person takes NO medications on a routine basis.

____ This person takes medications as follows (attach additional pages if needed):

Medication: Dosage: Times taken each day: Reason for taking:

THIS MUST BE SIGNED FOR CHILD TO ATTEND CAMP

PARENT AUTHORIZATION & PERMISSION TO TREAT: This health history is correct so far as I know, and

the person herein described has permission to engage in all prescribed camp activities, except as noted

by me and the examining physician. I hereby give permission to seek and authorize necessary medical

care in the event of an emergency. In the event that I cannot be reached in an emergency, I hereby give

permission to the physician to provide treatment, including hospitalization, for the person named

above.

Parent/Guardian Signature_______________________________________ Date____________________

MEDICAL EXAMINATION to be completed and signed by licensed medical personnel

Hgt: __________________________ Wgt: __________________________ B.P.:

__________________________

The applicant is under the care of a physician for the following conditions:

_____________________________________________________________________________________

(For Girls and Women) Has this person menstruated?____ If so, is her menstrual history normal?______

Special considerations___________________________________________________________________

Recommendations and restrictions while in camp_____________________________________________

Known allergies________________________________________________________________________

Special meal plans or diet restrictions______________________________________________________

Medications to be administered at camp (name, dosage, frequency if different from above):

_____________________________________________________________________________________

Limitations or restriction on camp activities__________________________________________________

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Additional information for camp health care personnel________________________________________

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I examined this individual on _____________________(date). In my opinion, the applicant is able to

participate in an active camp program.

SIGNATURE OF LICENSED MEDICAL PERSONNEL_____________________________________________

Print Name_________________________________________________________________________

Title_______________________________________________________________________________

Address____________________________________________________________________________

Telephone__________________________________________________________________________

Date_______________________________________________________________________________