Note: All Camps Are Free to ECASD Students

Blugold Beginnings Summer Camp 2015 Application Note: All Camps are Free to ECASD Students

Please check all that apply: Science, Technology, Engineering, Math (STEM) Camps (6 th -12 th grade) □ Session 1: Overnight in UWEC dorms: June 14th-19th, $275 per student □ Session 2: Day Camp: July 27th-30th (8a-5p), $175 per student Exploring the Arts (6th-12th grade) □ Session 1: Overnight in UWEC dorms: July 12th-16th, $250 per student □ Session 2: Day Camp July 6th-9th (8a-5p), $150 per student Dreaming Big, Planning Big – Entrepreneurship Camp (6 th - 12 th grade) □ Session 1: Overnight in UWEC dorms: June 21st- June 26th, $275 per student Bio-Medical and Kinesiology Camp (6 th -12 th grade) □ Session 1: Day Camp: August 3rd-August 6th (8a-5p), $175 per student Service and Leadership Camp (9 th -12 th grade) □ Session 1: Day Camp: July 20st-23rd (8a-5p), $100 per student Splashing into Middle School Camp (students entering 6 th grade) □ Session 1: August 10th-13th (8a-5p), $100 per student Please send completed application to: University of Wisconsin-Eau Claire Attn: Blugold Beginnings, Centennial Hall 1106 105 Garfield Ave Eau Claire, WI 54702-4004 2015 UW-EAU CLAIRE Blugold Beginnings Precollege Summer Camp Registration

Student Name: l a s t ______f i r s t ______m i d d l e

Date of Birth: __ M M / D D / Y Y Y Y Gender:  Male  Female

Current School Grade Level: School Attending: ______District Attending:

______

Race/Ethnicity –Check ALL that apply. a. What is the student’s race? Please check ALL that apply.  American Indian/Alaska Native – please specify principal WI or Other tribe & reservation  Asian Indian  Guamanian or  White  Native Hawaiian Spanish/Hispanic/Latino Chamorro  Black or African American  Hmong  Samoan  Cambodian  Japanese  Vietnamese  Chinese  Korean  Other Asian – please specify  Filipino  Laotian  Other race – please specify Student Primary Contact Information (primary phone number and address) Name: Relationship to Student: Street Address: City/State/Zip: Home Phone Number: Cell Phone: Work Phone Number: Student/Contact e-mail:

HEAD OF HOUSEHOLD 1 HEAD OF HOUSEHOLD 2 Have you earned a bachelors degree from a four- Have you earned a bachelors degree from a four- year college or university? ___No ___Yes year college or university? ___No ___Yes

Does your family qualify for or receive Free or Reduced lunches?  Yes  No

Is the student a Gear Up participant?  Yes  No I certify that the above information is true and correct to the best of my knowledge.

Student Signature Date

has my permission to participate in the Precollege Programs sponsored by the University of Wisconsin-Eau Claire and the Wisconsin Department of Public Instruction. I understand that the information provided will be used solely for program evaluation and program eligibility purposes and will be kept confidential.

Parent Signature Date

BLUGOLD BEGINNINGS HEALTH HISTORY QUESTIONNAIRE

______Name: Last First MI

______ADDRESS: Street City State Zip

Parent/Guardian:______Relationship:______

Home Phone: (______) ______-______Work Phone: (______) ______-______

Address (if different from above):______

Cell Phone: (______) ______- ______

In case of emergency (injury or illness), if you are unable to be contacted: Name: ______Relationship:______Phone: ______

Name of person on insurance card: ______

Name of Physician: ______Phone:______

Name of Insurance Co: ______Policy # ______

Date of Birth Sex Height Weight / /  F  M

Does participant have allergic reactions to: YES NO

□ □ Penicillin______□ □ Other Antibiotics______□ □ Other Medicines (type)______□ □ Insect Bites/Stings______

Immunization Record: *MMR (measles, mumps, rubella) Dose 1 – Immunization at 12 months _____/____/_____ Dose 2 _____/____/_____ *Tetanus-Diphtheria Year of initial series _____/____/_____ Year of last tetanus booster _____/____/_____

Have you ever had major surgery or been hospitalized?  YES  NO Please explain any significant operations, accidents or illnesses, and last medical attention and reason: ______

Does the participant have any physical condition(s) requiring special considerations?  YES  NO Explain:______Is participant taking any medication regularly?  YES  NO If yes, identify

Has participant had or presently experiencing:

YES NO YES NO

  Allergies   High Blood Pressure   Asthma   Joint Injury/Surgery

  Bleeding Disorder   Kidney Disease

  Cancer   Menstrual Difficulties

  Colitis   Mental/Emotional Prob.

  Diabetes   Neck/Back Pain/Injury

  Epilepsy/Seizures   Rheumatic Fever

  Heart Disease   Tuberculosis

  Hernia   Ulcer

Other: ______EMERGENCY CONSENT: In case of medical emergency, I/we understand that every effort will be made to contact me. If I/we can’t be reached, I/we authorize the Office of Multicultural Affairs staff at UW-Eau Claire to obtain whatever emergency treatment and/or care necessary for the health and well-being of the student ______Signature of parent/guardian Relationship Date PARENTAL CONSENT and PHOTOGRAPH RELEASE 2015 PRECOLLEGE PROGRAM(S)

I agree that the University of Wisconsin-Eau Claire and/or the UW-Eau Claire staff and/or employees shall not be held responsible for any personal injury, loss of, or damage to, property, however caused, and agree to release UW-Eau Claire, UW-Eau Claire staff and/or employees from all claims of damages which may arise as a result of any such personal injury or loss suffered during the course of the students participation in the Precollege Programs. All risks attendant to observing and/or participation in the Precollege Programs are assumed by the student and parent(s) and/or guardian(s). This assumption and release are acknowledged by the signatures below.

The University of Wisconsin-Eau Claire and/or the Office of Multicultural Affairs staff reserves the right to terminate the stay of any student, without refund and without formal hearing, when it is deemed by the University and program staff and employees. The University and the Office of Multicultural Affairs staff reserve the right to establish and determine the standards of conduct of participants engaged in the program and to require compliance with these standards as a condition of continued participation.

Signature of parent/guardian Relationship Date

PHOTOGRAPH RELEASE I understand that the University may take photographs of Precollege Program participants and activities. I agree that the University of Wisconsin-Eau Claire shall be the owner of and may use such photographs relating to the promotion of future Precollege Programs. I relinquish all rights that I may claim in relation to use of these photographs.

Signature of parent/guardian Relationship Date

2015 CODE OF CONDUCT AGREEMENT

Safety is our number one concern! In order to maintain a safe, productive, and fun learning environment, all students need to follow these guidelines. There will be consequences for any violations of these expectations:

 Students are responsible for attending all scheduled events on time.  Students are required to stay in the designated activity area for all structured activities including the evening activities. If you need to leave an activity, you need to get permission from the Blugold Beginnings’ staff. For safety reasons we need to know where you are at all times.  No student is allowed to leave the UW-Eau Claire campus unless given permission in advance from the Blugold Beginnings’ staff, who will confirm with your parents(s) or legal guardian(s) that you need to leave.  The use of alcohol and drugs, including tobacco is strictly prohibited.

Overnight Camp Only:  Remain in your assigned residence hall room after 10 p.m. until 7 a.m., unless there is an emergency (i.e., illness, fire drill, etc.)  Outside visitors are NOT allowed at the residence hall, any unexpected visitors will be asked to leave immediately.

I agree with and will abide by, the code of conduct agreement during my attendance. I understand that my participation is a privilege and I will respect others and myself. I understand that if the Blugold Beginnings finds my behavior inappropriate they will call my parents(s) or legal guardian(s) for immediate pick-up at their expense.

Signature of participant Date

Signature of parent or guardian Date YOU MUST RETURN THIS SIGNED AGREEMENT WITH YOUR COMPLETED APPLICATION MATERIALS.

Wisconsin Department of Public INSTRUCTIONS TO THE STUDENT AND PARENT/GUARDIAN: Student must be eligible for Free or Reduced Price School Meals and, must Instruction have finished Fifth Grade, but not have graduated from High School to receive a DPI Precollege Scholarship. Fill out Section I completely. Parent/Guardian PRECOLLEGE SCHOLARSHIP must sign in the space provided. Give this form to your Principal, Food APPLICATION Services Authorized Representative or a DPI/WEOP Staff Member for PI-1573 (Rev. 04-12) completion of Section II. Students who are disruptive or sent home from a Precollege Program may forfeit the opportunity to participate in future programs.

Please submit this completed form with your Blugold Beginnings application, please mail to the following address: University of Wisconsin-Eau Claire, Attn: Blugold Beginnings 105 Garfield Avenue, Eau Claire, WI 54702

You may receive a maximum of three DPI Precollege Scholarships per year. I. STUDENT INFORMATION Name Last First Middle Initial

Street Address City State Zip

Date of Birth Sex

Male Female

Check only one (For Statistical Purposes)

Hispanic or Latino Not Hispanic or Latino

Check all that apply

American Indian or Alaska Native Asian Black or African-American Native Hawaiian/Other Pacific Islander White

Current Grade Level Anticipated Year of High School Graduation

School Presently Attending School District Name

I HEREBY AUTHORIZE release of my child’s verification of Free or Reduced Price School Meals eligibility to the Precollege Campus and DPI. Signature of Date Signed Mo./Day/Yr. Parent/Guardian

II. VERIFICATION AND RECOMMENDATION Instructions to the Principal, Food Services Authorized Representative, or DPI/WEOP Staff Member: Please verify that this student is eligible for Free or Reduced Price School Meals and forward this application form to the College or University where the student has applied for admission to a DPI Precollege Program.

Is this student eligible for Free or Reduced Price School Meals? Yes No I have verified that this student is eligible for Free or Reduced Price School Meals and I recommend this student for a DPI Precollege Scholarship. Name of Authorized Title Telephone Area/No. Representative

Verification Signature Date Signed Mo./Day/Yr. 