Athletics

Yes

Chaperones

Yes

Media

Yes

Transportation

Yes

Research

Yes

Parents and legal guardians are responsible for carefully reviewing all program materials and for selecting programs that are appropriate for their child. Information regarding University of Michigan sponsored programming for children and teens is available at:

childrenoncampus.umich.edu

PROGRAM INFORMATION

Program Name

Program Contact

Phone Number

Email Address

Program Start Date

PARTICIPANT INFORMATION

Legal First Name

(hereafter "Participant")

Middle Initial

Legal Last Name

Preferred First Name

Gender

Date of Birth

Current/Mailing Address

Country

United States (Including Minor Outlying Islands)Other

Country

Address

City

State

State/Province

Postal Code

Is this your permanent address?

YesNo, this is an alternate address

Permanent Home Address

Country

United States (Including Minor Outlying Islands)Other

Select your country.

Address

City

State

State/Province

Postal Code

Phone/Email

Participant's Email Address (If any)

Participant's Phone Number Preferences (If any)

Mobile Phone

Numbers only, including area code.

Home Phone

Numbers only, including area code.

Other Phone

Primary Phone Preference

Academic Information

Current Grade Level

Name of Current School

School Street Address

City

State

Postal Code

Country

PARENT/GUARDIAN INFORMATION

Legal First Name

Middle Initial

Legal Last Name

Relationship to Participant

CONTACT DETAILS

Permanent Home Address

Same as ParticipantOther Address

Country

United States (Including Minor Outlying Islands)Other

Select your country.

Address

City

State

State/Province

Postal Code

Phone/Email

Parent's Email Address

Parent's Phone Number Preferences

At least one phone number is required.

Mobile Phone

Home Phone

Other Phone

Numbers only, including area code.

Primary Phone Preference

PARTICIPANT CONDUCT AGREEMENT

This Program has established rules and standards of conduct for all Participants. It is the responsibility of the Parent/Legal Guardian and the Participant to review the Program rules and standards of conduct. Dismissed Participants are not eligible for a refund of any fees or expenses. The Parent/Legal Guardian is responsible for all costs associated with removing the Participant from the Program due to his/her misconduct, including but not limited to transportation costs to return the Participant home.

PARTICIPATION AGREEMENT

The Participant understands that as a condition for participating in the Program that he/she must comply with the Program’s rules and standards of conduct and follow all reasonable direction of the Program Staff. Failure to comply with the Program’s rules and standards of conduct or failure to comply with the reasonable direction of Program Staff may result in the Participant being dismissed from the Program.

PARENT/GUARDIAN AGREEMENT

I acknowledge that I have reviewed the Participation Agreement above with my child. I understand that my child will be subject to the rules and standards of conduct of the Program and the University of Michigan. I further understand that my child’s violation of the rules and standards of conduct or failure to comply with the reasonable direction of Program Staff may result in my child’s dismissal from the Program. I accept responsibility for all costs associated with removing my child from the Program, including but not limited to transportation costs to return the Participant home.

COMMUNICATION PREFERENCES/PRIVACY PROTECTION

Parent/Guardian Communication Preference

I, Parent/Guardian, would like to receive communications (print and/or electronic) from the University of Michigan regarding academic or other enrichment opportunities for youth at the University of Michigan.

Minor Communication Preference

I, Parent/Guardian, would like my child to receive communications (print and/or electronic) from the University of Michigan regarding academic or other enrichment opportunities for youth at the University of Michigan.

The University may use demographic and program participation information collected through this form for research and quality assurance purposes.

PICK UP AUTHORIZATION

My son/daughter is at least 16 years of age and will be responsible for his/her own transportation to and from Program. My son/daughter may sign him/herself in at the start of Program activities and sign him/herself out at the end of Program activities.

YES, my son/daughter is at least 16 years of age and will be responsible for himself/herself NO, my son/daughter is not at least 16 years of age and will not be responsible for himself/herself

AUTHORIZED PERSONS

Please list any individual who is authorized to pick up your child, including yourself. Each authorized person must be at least 16 years of age. The above-named Participant will not be permitted to leave the Program with anyone who is not listed below. Authorized individuals must pick up children in person and may be requested to show identification to Program staff when picking up a Participant. Participants will not be released to persons who fail to provide acceptable identification upon request.

I authorize the following responsible person to pick up my child from the aforementioned Program activities:

Authorized Person

First and Last Name

Phone Number

Numbers only, including area code.

Relationship to Child

UNAUTHORIZED PERSONS

Are there any individuals whom you would like to specify who are not permitted to pick up your child?

YesNo

Unauthorized Person

First and Last Name

Brief Physical Description

Relationship to Child

MEDIA, PHOTO & VIDEO RELEASE

By selecting YES below:

I understand that during the course of my child’s participation in the above-referenced activity, that the Program, and those acting with the Program’s permission or authority, may capture my child’s name, likeness, image, or voice in photographic, audio, video, digital or other recordings. I give my permission for the Program to use those recordings or works produced by my child (e.g., art work) for promotional, commercial, informational, and educational purposes in any and all media (including the Internet) now existing or hereafter devised, for any purpose consistent with the Program’s mission. I understand that I will not have an opportunity to review or approve uses of the Recordings or Works.
I recognize that the Program, through the Board of Regents of the University, holds the copyright in all Recordings. I understand that neither my child nor I will receive payment or any other compensation for the taking or use of any Recordings or Works created as a result of my child’s participation in the Program.
I release, indemnify and hold harmless the University from and against all liability, actions, debts, claims and demands of every kind whatsoever to the taking or use of the Recordings or Works of my child.

By selecting NO below:

I do not grant permission to Program to take or use my child’s name, likeness, image, or voice in any form or to use work produced by child for any reason unless necessary for the administration of the Program while my child is participating in the Program.

Please choose one:

YESNO

MEDICATION AUTHORIZATION TO TREAT

The University requests certain medical information so that the Program staff can properly plan to meet the needs of each participant and, in case of emergency, that we have accurate information to provide and/or seek appropriate treatment for the Participant. You are responsible for providing accurate and complete information. Please answer the following questions and then download and complete all forms indicated below; completed forms should be returned to the Program.

Will the Participant require Over-the-Counter (OTC) medications during the Program?

YesNo

Will the Participant require prescription medication(s) during the Program?

YesNo

Will the Participant self-administer the required prescription medication(s) during the Program?

YesNo

REQUIRED FORMS

Protecting your privacy is important to the University of Michigan. The forms below contain health information protected by law. As such we request that these forms be downloaded, printed, and returned to the program contact securely per the program's instructions.

To download the forms, right-click (Windows) or control-click (Mac) each of the links below and choose "Save link as" to download forms to your computer. These files can be opened on your computer for printing. Alternatively, simply clicking a link will open the form in another tab in your web browser; you can use your browser's menu to print a form. Please know that data typed into a form in your web browser will not be saved to your computer.

Download the following form(s):

Medical Authorization to Treat (Required for all programs)

Over-the-Counter Medication Authorization

Self-Administration of Prescription Medication

PROGRAM CONTACT

Completed forms should be returned to the Program. Please contact the individual below for additional information.

Program Contact

Phone Number

Email Address

STATE OF MICHIGAN PARENT & ATHLETE CONCUSSION INFORMATION

Michigan State Law requires operators of athletic activities for youth athletes to provide Sports Concussion Awareness Training through the following educational materials on the signs/symptoms and consequences of concussions to each youth athlete and their parents/guardians. Please initial below acknowledging receipt of the information. To learn more go to cdc.gov/concussion. (Content Source: CDC’s Heads Up Program.)

WHAT IS A CONCUSSION?

A concussion is a type of traumatic brain injury that changes the way the brain normally works. A concussion is caused by a bump, blow, or jolt to the head or body that causes the head and brain to move quickly back and forth. Even a “ding,” “getting your bell rung,” or what seems to be a mild bump or blow to the head can be serious.

WHAT ARE THE SIGNS AND SYMPTOMS OF A CONCUSSION?

Signs and symptoms of concussion can show up right after the injury or may not appear or be noticed until days or weeks after the injury. If an athlete reports one or more symptoms of concussion after a bump, blow, or jolt to the head or body, s/he should be kept out of play the day of the injury. The athlete should only return to play with permission from a health care professional experienced in evaluating for concussion.

SYMPTOMS REPORTED BY ATHLETE:

Headache or “pressure” in head
Nausea or vomiting
Balance problems or dizziness
Double or blurry vision
Sensitivity to light
Sensitivity to noise
Feeling sluggish, hazy, foggy, or groggy
Concentration or memory problems
Confusion
Just not “feeling right” or is “feeling down”

SIGNS OBSERVED BY COACHING STAFF:

Appears dazed or stunned
Is confused about assignment or position
Forgets an instruction
Is unsure of game, score, or opponent
Moves clumsily
Answers questions slowly
Loses consciousness (even briefly)
Shows mood, behavior, or personality changes
Can’t recall events prior to hit or fall
Can’t recall events after hit or fall

CONCUSSION DANGER SIGNS

In rare cases, a dangerous blood clot may form on the brain in a person with a concussion and crowd the brain against the skull. An athlete should receive immediate medical attention if after a bump, blow, or jolt to the head or body s/he exhibits any of the following danger signs:

One pupil larger than the other
Is drowsy or cannot be awakened
A headache that gets worse
Weakness, numbness, or decreased coordination
Repeated vomiting or nausea
Slurred speech
Convulsions or seizures
Cannot recognize people or places
Becomes increasingly confused, restless, or agitated
Has unusual behavior
Loses consciousness (even a brief loss of consciousness should be taken seriously)

WHAT SHOULD YOU DO IF YOU THINK YOUR ATHLETE HAS A CONCUSSION?

If you suspect that an athlete has a concussion, remove the athlete from play and seek medical attention. Do not try to judge the severity of the injury yourself. Keep the athlete out of play the day of the injury and until a health care professional, experienced in evaluating for concussion, says s/he is symptom-free and it’s OK to return to play.
Rest is key to helping an athlete recover from a concussion. Exercising or activities that involve a lot of concentration, such as studying, working on the computer, and playing video games, may cause concussion symptoms to reappear or get worse. After a concussion, returning to sports and school is a gradual process that should be carefully managed and monitored by a health care professional.
Remember: Concussions affect people differently. While most athletes with a concussion recover quickly and fully, some will have symptoms that last for days, or even weeks. A more serious concussion can last for months or longer.

WHY SHOULD AN ATHLETE REPORT THEIR SYMPTOMS?

If an athlete has a concussion, his/her brain needs time to heal. While an athlete’s brain is still healing, s/he is much more likely to have another concussion. Repeat concussions can increase the time it takes to recover. In rare cases, repeat concussions in young athletes can result in brain swelling or permanent damage to their brain. They can even be fatal.

Parent/Guardian Initials

PARTICIPATION & AGREEMENT WAIVER

I understand that my child’s participation in the Program is voluntary and that as I condition of my child’s participation, I agree to comply with all Program requirements including, but not limited to: (a) accurately completing all registration forms in a timely manner, (b) ensuring that my child is aware of the Program’s standards of conduct; (c) and immediately notifying the Program Administrator of any concerns related to the health, safety or security of my child, other participants, or Program staff.

I understand that as part of my child’s participation in the Program that there are dangers, hazards and inherent risks to which my child may be exposed, including the risk of serious physical injury, temporary or permanent disability, and death, as well as economic and property loss. I further realize that participating in the Program may involve risks and dangers, both known and unknown, and I have chosen to allow my child to take part in the Program. Therefore, I, and on behalf of my child, have determined that it is reasonable to accept all risk of injury, loss of life or damage to property arising out of training, preparing, participating, and traveling to or from the Program and I do voluntarily accept and assume those risks. I release the University of Michigan, its Board of Regents, Administration, Faculty, Staff, Graduate Students, and all other officers, directors, employees, volunteers and agents from any claims or liability arising from my child’s participation in the Program, provided that such claim is not due to the gross and sole negligence of the released parties.

In the event of an accident or serious illness, I authorize representatives of the University to obtain medical treatment for my child. I hold harmless and agree to indemnify the University from any claims, causes of action, damages and/or liabilities, arising out of or resulting from said medical treatment. I further agree to accept full responsibility for any and all expenses, including medical expenses that may derive from any injuries to my Child that may occur during his/her participation in the Program.

I also agree to indemnify the University and all of its employees and agents from any financial obligations or liabilities that my child may cause while participating in the Program, including attorney’s fees and court costs resulting from his/her misconduct, errors, or omissions.

I acknowledge that University employees and its volunteers have undergone criminal background checks, but other participants of the event may not have undergone background check screening. As such, the University makes no assertions or assurances with respect to other participants.

CHAPERONES

I acknowledge that the adult chaperones for my child's school/organization are responsible for the supervision of my child during the Program. Accordingly, I understand that the University makes no assertions or assurances regarding background screening of the adult chaperones of other participants.

TRANSPORTATION

I give permission for the University to provide transportation of my child as a participant in the program, to and from all events under the supervision of Program staff. I understand that University of Michigan leased vehicles will be used to transport my child to and from Program events.