Locked in to Stay

Registration forms can be found here:http://www.siue.edu/pharmacy/about/news/pharmacy-calendar.shtml www.facebook.com/SIUELockinToStayOut GenerationRx is a patient care project within American Pharmacists Association – Academy of Student Pharmacists (APhA-ASP). The mission of GenerationRx is to provide education to people of all ages about the potential dangers of misusing prescription medications. Through this, we encourage medication safety to youth in our communities. The Southern Illinois University Edwardsville (SIUE) School of Pharmacy APhA-ASP GenerationRx will be hosting an overnight lock in beginning on Saturday, April 4, 2020 for 5th through 8th grade students at the SIUE Vadalabene Center in Edwardsville. Research has shown that elementary students who participate in programs focused on prescription drug misuse are less likely to abuse prescription medications as adults. ALL parents/guardians are strongly Who: 5th through 8th grade students encouraged to attend the parent orientation What: Overnight lock in meeting starting immediately after child registration for an open discussion regarding Where: SIUE Vadalabene Center Edwardsville Campus prescription drug misuse within the When: Saturday-Sunday, April 4, 2020 community, what your child will learn Check in begins at 8:00pm Saturday, April 4 throughout the evening and to answer Student & Parent Orientation at 8:30pm questions regarding this topic. Pick-up 7:30-8:00am Sunday, April 5, 2020 Registration Information Event Includes: • Cost: $20 Donation Suggested (this money will be used to offset • Lock in t-shirt the cost of the event for the evening and to extend future • Drawstring bag offerings of community engagement to adolescents within our • Raffle prizes community) • Pizza, snacks, drinks • Completed registration forms and waivers must be mailed to • Interactive learning address listed on registration form • Rock climbing • Registration deadline is Monday March 2, 2020 • 3 hours of open court play • Wallyball/Volleyball What to Bring/Wear: • Indoor soccer • Sleeping bag/blanket/pillow (optional) • Basketball • Empty water bottle (optional) • Dodgeball • Evening/emergency medicine MUST be checked in at registration • Kickball • Sweatpants/shorts encouraged • Meeting other students • Tennis shoes & socks for rock climbing, and gym play • Movies If you have questions or would like additional information please email [email protected] or call Dr. Jessica Kerr at 618-741-0630 GENERAL INFORMATION DIRECTIONS Please see the attached campus map. Parking is available in lot F. MEDICATION (PRESCRIPTION ONLY) All prescription medication must be in their original container with the information clearly labeled on the container. Only prescription medication will be given during the lock in. All medication must be handed in at the check in table. ILLNESS & EMERGENCY TREATMENT Student health and safety are our top priority at the lock in. If your child has a serious accident or illness or requires medical treatment by a doctor, you will be notified immediately. Please be sure to provide the necessary insurance and emergency contact information on the registration form. DROP OFF AND PICK UP POLICY In order to ensure the safety of your child, all students must be signed in when they are dropped off and signed out when they are picked up. You will notice that part of the registration packet is a pick up form. You will need to list anyone that may be picking up your child on this form. We will check identification to verify the adult, therefore please remember to have your picture identification ready. Your child will not be allowed to go home with anyone who is not on the list. Check in will begin at 8pm on Saturday in the Vadalabene Center lobby. All students must be checked in by a parent or guardian. Parent orientation will start promptly at 8:30pm (optional but encouraged). Pick up from the Vadalabene Center on Sunday will be from 7:30-8am. DISCIPLINE POLICY To ensure that all children have a good experience at the lock in, it is expected that each child be courteous and respectful of fellow participants and the volunteers. Our discipline policy includes verbal warning. A continuous pattern of negative behavior or any major incident will result in immediate parent contact to pick up your child. The volunteers will do everything possible to make sure your child’s experience is safe and enjoyable. Your cooperation and involvement is important to the success of the lock in. DO NOT BRING Do not bring personal listening devices, cell phones, computers, electronic games, food of any kind, or any inappropriate items to the lock in. Items such as these ARE BROUGHT AT YOUR OWN RISK and may be collected and held for the duration of the lock to be returned to parents at the end of the lock in. Valuables (jewelry, money, etc.) should also be left at home. We request that students do not wear open toe shoes, sandals or flip flops. All personal items brought to the lock in (water bottle, sleeping bag, pillow, etc) should be marked with the student’s name. Event coordinators are not responsible for lost items. Locked in to Stay Out Registration Form PARTICIPANT INFORMATION First Name _______________________________ Last Name ____________________________________ School ____________________________________ Grade ______ Birthdate ____________ Gender _____ Address: ________________________________________________________________________________ City ______________________________________ State ____________ Zip ____________________ T-shirt Size (circle): Youth: S M L Adult: S M L XL 2XL 3XL HEALTH INSURANCE INFORMATION Insurance Company ____________________________________________ Policy Number _______________________________ Subscriber Name _________________________________________ Insurance Company Phone __________________________ MEDICAL AUTHORIZATION Does the participant have any allergies (including food allergies)? No _____ Yes _____ If yes, please provide details: ___________________________________________________________________________ ________________________________________________________________________________________ Please provide details of any current or recent medical conditions, diseases, disorders or problems: ________________________________________________________________________________________ Is any special care, prescription medication, or diet required? Over the counter medications will not be given without a valid prescription. No _____ Yes _____ If yes, please list: ______________________ ________________________________________________________________________________________ Does your child have any special dietary needs? No _____ Yes _____ If yes, please list: _______________ ________________________________________________________________________________________ CONSENT OF TREATMENT I hereby authorize the Southern Illinois University Edwardsville to provide or obtain emergency medical care for __________________________________________, a minor. I understand that I will be responsible for any charges incurred for such care. Parent/Guardian Signature __________________________________ Telephone ___________________ Relationship to Minor ___________________________________________ PARENT/GUARDIAN INFORMATION/AUTHORIZATION As the parent/legal guardian of ______________________________________ (student’s name), I grant him/her permission to attend the Locked in to Stay Out lock in with SIUE School of Pharmacy at the SIUE Vadalabene Center. I understand that all registration forms and waivers are due to the address listed below by March 2, 2020. Parent/Guardian Signature _______________________________ Date ____________ Parent/Guardian Email (for communication regarding lock in)_______________________________________ EMERGENCY CONTACT/PICK UP LIST Please list all the possible people that you would like contacted in case of an emergency or may pick up your child. Please make them aware that lock in volunteers will be checking photo identification to ensure your child’s safety. Lock in volunteers will not allow your child to go home with anyone not on this list. Thank you. Name: ___________________________________ Phone: _______________________________ Relationship: ______________________________ Email: _______________________________ Name: ___________________________________ Phone: _______________________________ Relationship: ______________________________ Email: ________________________________ Name: ___________________________________ Phone: _______________________________ Relationship: ______________________________ Email: ________________________________ PHOTOGRAPH RELEASE I, (print name)___________________________________________, parent or official guardian of (child’s name)____________________________________________hereby consent and grant permission to the Board of Trustees of Southern Illinois University Governing Southern Illinois University Edwardsville, its employees, and representatives (collectively SIUE) to take and use photographs, videotapes, digital images, or otherwise recorded images of my child and to publish such images or depictions for promotional, marketing, or educational purposes in any form, including, but not limited to print, electronic, video, or Internet. I also hereby consent and grant permission to SIUE to edit, crop, retouch, or otherwise alter such images or depictions of my child, I waive any privilege to inspect such images or depictions prior to publication, and I authorize the use of these images indefinitely

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