Registration Packet

Take Your Child to Work Day Thursday, April 28, 2016 8:30 AM to 4:30 PM Registration Packet

Requirements and Information q 1. Complete one Registration Packet for each child that is participating. Note: a completed registration packet consists of: Registration Form, Medical Release and Minor Release Form. A Parental Authorization must be completed if someone other than the parent will be responsible for bringing the child to the event. q 2. This program is for children in 2nd grade up to 12th grade. q 3. Children will be placed in the Elementary, Middle School or the High School group, whichever is age appropriate. Children will participate in activities with their assigned groups. There will be at least two adults assigned to each group. q 4. Children Must wear closed-toed shoes for this event (flip-flops, sandals, high heels, or crocs are not permitted). q 5. Lunch will be provided. If your child has dietary restrictions and cannot eat what’s provided, then parents will be responsible for providing this information on the Registration Form in this packet. If the lunch option does not meet the dietary needs, then the parent is asked to provide a lunch for their child. q 6. A healthy snack will be provided in the morning. Parents are asked to ensure that their child has a substantial breakfast before signing in to the event. q 7. Parents/guardians of students that are participating in the Take Your Child to Work Day event must call in an excused absence to your child’s school. q 8. Parent / guardian must sign children in by 8:30 am at the USC Ballroom 1. Children may not be dropped off or sent in on their own. q 9. There should be ample time for restroom usage between activities; however, parents are asked to encourage their children to make their needs know as soon as possible. Children will be escorted to the restrooms by an adult volunteer. q 10. Parents are invited to join their children at lunchtime. Please note your attendance on the Registration Form in this packet. q 11. Sign in and pick up will be in SLC Multipurpose Room. q 12. Return the completed form (Registration Form, Medical Release Form, Minor Release Form, and if applicable the Parental Authorization) by April 11, 2016 to: Human Resources, Bay 206, or scan and email to: [email protected]. Space is limited.

Website The following website will contain current information on the 2016 Take Your child to Work Day at USF St. Petersburg. Check the website frequently for updated information and additional copies of forms.

After the event, your will find pictures of the day’s activities on the website along with a list of our program partners. http://www.usfsp.edu/human-resources/take-your-child-to-work-day-2/

Keep this page for your information Take Your Child to Work Day Thursday, April 28, 2016 8:30 AM to 4:30 PM REGISTRATION FORM

If this program is of interest to you and your child, please print and fill out a separate registration form and authorization/medical release form for each child.

Submission of this form secures a spot for your son/daughter in the Take Your Child to Work program at USF St. Petersburg.

This program is only for children in the 2nd Grade up to high school. Snacks and lunch will be provided.

Name of Child: Grade in School:

Parent’s Name:

Campus Department and Mail Code:

E-mail address: Campus Phone Number:

Home/Cell Phone Number:

Please explain if your child has any special requirements:

List the names of other children that you would like your child to be in the same group with:

How many parents/guardians will be attending the luncheon with their child (ren)?

Children must wear closed-toed shoes for this event (flip-flops, sandals, high heels, or crocs are not permitted).

If you choose to have your child shadow you before or after the formal program, it will be necessary to inform your supervisor. If your child is unable to shadow you at work; you will need to make arrangements for her/him, as no childcare will be provided before or after the formal program.

Parent’s Signature: ______Date: ______

Return by April 11, 2016 to: Human Resources, Bay 206 Or by email to [email protected] Take Your Child to Work Day Thursday, April 28, 2016 8:30 AM to 4:30 PM

1 Parental Authorization Form

Note: Complete one Parental Authorization Form for each child participating if you are authorizing another adult to bring your child to USFSP to participate in the Take Your Child to Work Day events.

I/We, the undersigned, grant our son/daughter (Name of Student) permission to participate in Take Your Child To Work Day, an out-of-school educational program, provided by USF St. Petersburg. Should a medical emergency arise while my son/daughter is participating in this program, the accompanying adult or I will be responsible for initiating medical treatment. I give permission for immediate treatment as required in the judgment of the attending physician. If there are any changes to the information provided herein, it is the parent’s responsibility to provide the updated information.

Parent’s Signature: ______Date: ______Take Your Child to Work Day Thursday, April 28, 2016 8:30 AM to 4:30 PM

Return this page with the completed packet. 2 Medical Release Form

Note: Complete one Medical Release Form for each child participating.

Name of Student: Date of Birth:

Home Address:

Name of Parent/Guardian Relationship:

Campus Phone Number:

Alternate Contact:

Home/Cell Phone: Work Phone:

Name of Family Physician:

Phone Number:

Medical Insurance Information

I attest that my son/daughter has medical insurance coverage through:

(Name of Insurance Company) (Policy Number) (Group Number)

Medical Condition of Student: Excellent Good Fair

If applicable, please describe any medical condition that may recur. (State none if the statement does not apply to your child.)

Is your son/daughter allergic to any medicine? Yes No

If yes, describe: Take Your Child to Work Day Thursday, April 28, 2016 8:30 AM to 4:30 PM Parent’s Signature: ______Date: ______

Return this page with the completed packet. 3 Minor Photo Release Form

I do hereby grant to Photographer, HR Personnel, and to his/her employees or assigns, permission to

photograph and/or capture video of the minor indicated below, and use such imagery in any manner

consistent with the promotion of the University of South Florida, and its affiliated agencies. Such use to

include, but is not limited to: publication, display, advertising, editorial illustration, web use, broadcast, etc.

I hereby swear that I am the legal guardian of said minor, that I am of sound mind and body, and I agree to

all terms stated above.

Description of Shoot: Take Your Child to Work Day activities

Subject’s Name:

Legal Guardian (Name Printed):

Legal Guardian (Signature):

Date: Take Your Child to Work Day Thursday, April 28, 2016 8:30 AM to 4:30 PM Witness:

Return this page with the completed packet. 4