Cougar discovery-student-information-packet

1. June 27-30, 2016
Washington State University Tri-Cities
Richland, WA
Student Information
Parent/Guardian Information
Emergency/Medical Information
First name: ___________________________ Last name: ____________________________ MI: ______
Male ____ Female ____ High School: _____________________________________________________
Fall 2016 Grade Level: 9 ___ 10 ___ 11 ___ 12 ___ Birthdate: __________________/______/_________
Home mailing address:_______________________________________ State: _____ Zip Code:________
Preferred Phone: (____)__________________ E-mail: ________________________________________
First name: ______________________________ Last name: ___________________________________
Home mailing address:______________________________________ State: ______ Zip Code:________
Home phone: (____)__________________ Cell Phone: (____)__________________ Text? Yes ___No___
Work phone: (____)_________________ E-mail: ____________________________________________
Name: _________________________________ Relationship to student:__________________________
Contact Phone: (____)___________________ E-mail: ________________________________________
Name of Primary Doctor(s): _________________________________ Phone: (____)_________________
Primary Insurance Company: _____________________________________________________________
Policy Number: __________________________________ Subscriber: ____________________________
Insurance Company Phone Number: (_____)______________________
This student is covered by family medical and/or hospital insurance. No______ Yes ______, information is provided below:
In an emergency requiring medical attention or a situation reasonably believed by Washington State University (WSU) authorized agents to be an emergency, I authorize WSU and
its authorized agents to obtain emergency medical care for my student. I will be responsible for any expenses incurred in so doing including but not limited to care by health care
professionals, hospital care, and ambulance or other services. In addition, the health care provider has permission to obtain a copy of my student’s health record from providers who
treat my student and these providers may talk with the program’s staff about my student’s immediate health status. NOTE: Minors may consent to certain services in Washington.
I hold harmless and agree to indemnify WSU, its authorized agents and employees from decisions to seek emergency treatment.
Emergency contact in case of illness or injury if parent(s)/guardian listed above cannot be reached:
Emergency Medical Release:
Health-Care Providers:
Medical Insurance Information:
Contact information for parent/guardian with residential placement and/or decision-making authority in the event of illness or injury:
Immunizations:
My student is up-to-date on his/her immunizations and tetanus shots as required by Washington State law.
My student has an immunization exemption on file with his/her school. I understand and accept the risks to my student from not being fully
immunized.
Medications: “Medication” is any substance a person takes to maintain and/or improve their health; this includes vitamins and natural remedies.
This student will not take any daily medications while attending the activities.
This student will be self-administering medication(s) while attending the activities.
Washington State University staff cannot administer medication to students. If your student requires a dosage during camp hours, please make appropriate arrangements. All
medication sent with the student to camp must be in their original containers. Prescriptions must have the student’s name and how the medication should be given printed on
the prescription container. Please send only those medications that are necessary.

2. Allergies: Check any that apply to this student.
Mental, Emotional, and Social Health: Check “Yes” or “No” for each statement. Has the student:
No known allergies
This student has a life-threatening allergy. If this box is checked, an emergency care plan signed by a physician must be provided.
This student is allergic to: (Please list, describe reaction seen, and preventative or responsive measures.)
Foods: ______________________________________________________________________________________________________________
Medicines: ___________________________________________________________________________________________________________
Environmental (insect stings, hay fever, etc.): _______________________________________________________________________________
Other: ______________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
1. Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (ADHD)?........................
2. Ever been treated for emotional or behavioral difficulties or an eating disorder?...........................................................
3. During the past 12 months, seen a professional to address mental/emotional health concerns?......................................
Yes
Yes
Yes
No
No
No
Please explain “Yes” answers in the space below, noting the number of the question. The camp may contact you for
additional information. ___________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Name of medication Date started Reason for taking When it is given Amount or dose given How it is given
Restrictions and Accommodations: Check all that apply.
I feel my student can participate without restrictions.
My student does not require reasonable accommodations for a disability in order to access or be part of the activities.
I feel my student can participate with the following restrictions or adaptations. Please describe below:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
I request reasonable accommodation for a disability in order for this student to access or be part of the activities. Please describe:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
The above information is correct and accurately reflects the student to whom it pertains. The person described has permission
to participate in all program activities except as set forth above by me and/or an examining physician. I understand this form
will be shared on a “need to know” basis with WSU staff. I give permission to copy this form for those purposes. I voluntarily
sign this authorization in consideration for permission for my student to participate in the WSU Tri-Cities Cougar Discovery High
School Summer Academic Camp in Richland, Washington. I have read it, and I understand its content and significance.
(BOTH SIGNATURES ARE REQUIRED.)
__________________________________________________________________ ________________________________
Signature of Parent/Guardian Date
__________________________________________________________________ ________________________________
Signature of Witness Date
Note: Witness need not be a notary or have an official position. They may be spouses, friends, or co-workers.
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PAGE 2 COUGAR DISCOVERY REGISTRATION FORM

3. Photo and Promotional Purposes Consent
YES: Images or voice recordings may be used as set forth below:
NO: Images or voice recordings may not be used as set forth below:
• Permission is granted as noted above to WSU for the student to be photographed or otherwise have images or voice recordings made (in-
cluding but not limited to photographs, moving images and/or voice recordings), for WSU publication or promotional purposes in any medium
(including but not limited to print and digital media).
• The student’s name and/or interview comments may be used in connection with WSU publication or promotional purposes in print media,
newspaper, television, video, motion picture, or other electronic media.
• The use of the student’s likeness or voice recordings is not a condition of participating in the activity and that consent may be refused without
any impact in the ability to fully participate in the program.
• No inducements or promises beyond this acceptance of an opportunity to promote WSU and its programs have been given to the persons
signing this form.
• Any other use of images and/or recordings, names, and/or interview comments requires advance permission.
• The Image and Voice Recordings Consent may be revoked at any time upon notice to WSU, at which time the parent/guardian will sign a copy
of the denial for use of images or voice recordings.
WSU may share campers activities on its website for the enjoyment of campers and their family and friends. Local media often
requests to attend camp to capture the students’ learning activities to share with their viewing audiences. The purpose is to high-
light the accomplishments of your child and success. Please let us know your preferences below:
Transportation Authorization
Food Allergy(s)/Intolerances
Please check the boxes below as your authorization for approved transportation methods to be used by your student to leave
the Cougar Discovery Camp and the WSU Tri-Cities campus, at the end of the camp day, or with prior written notification by you to
the camp director, leave during a camp day, and leave during a camp day for medical or other appointments. All participants are
asked to arrive at WSU Tri-Cities by 8:30 a.m. each day prepared to follow instructions.
Please provide medical documentation describing the dietary restrictions due to the food allergy and/or intolerance, from the
Participant’s Physician (MD or DO). CHECK ALL THAT APPLY:
WSU Tri-Cities and its food vendors does not provide assistance or administer injections due to allergic reactions and does not carry
or provide stock epinephrine. Every attempt to meet special diet and food allergy needs will be made, but it is not possible to
guarantee food service for all food allergies. Students with specific dietary needs are welcome to bring their own lunch each day.
CHECK ONLY IF YOUR STUDENT IS SERVED UNDER WSU TRI-CITIES GEAR UP
Food Allergy: ______ Dairy ______ Soy ______ Eggs ______ Peanuts ______ Tree Nuts ______ Fish ______ Shellfish ______ Wheat
Other, please list: ______________________________________________________________________________________________________
Food Intolerance: ______ Gluten (celiac disease or non-celiac gluten sensitivity, includes wheat, barley, oats, rye)
______ Lactose ______ MSG ______ Other, please list: _________________________________________________________
My student has my authorization to travel alone, and/or leave camp with a family or non-family member (for example: another student or parent)
My student will wait in the check-out room before being allowed to leave with the following person(s) who must provide photo ID to staff:
Other Special Diet needs or restrictions (i.e., Diabetes, IBS, other): _______________________________________________________________
_____________________________________________________________________________________________________________________
Types of contact that will cause a reaction: ______ Airborne _____ Trace Cross-Contact _____ Actual ingestion of food _____ Other
Please explain reaction: __________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Print First and Last Name below: Relationship to Student: Contact Phone:
___________________________ ___________________________ __________________________
___________________________ ___________________________ __________________________
Does the Participant understand the food allergy and what needs to be done to manage it? Is there any other
information you would like to share to help us meet the Participant’s needs?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
PAGE 3 COUGAR DISCOVERY REGISTRATION FORM

4. Code of Conduct
Computers and Mobile Electronic Devices
Dress Code & Cancellation or “No Show” Policy
Completing Registration
It is not recommended that students bring electronic devices other than a cell phone for use during lunch breaks and
after camp hours. During program sessions and activities, distracting and inappropriate use of any personal electronic
devices which may include, but not limited to, cell phones, laptops, tablets, cameras, and MP3 players will result in
confiscation of the device available for claiming at the end of the day. WSU Tri-Cities and Cougar Discovery will uphold
the electronic devices policies set forward by the student’s school district and will not be responsible for lost, stolen, or
damaged personal items.
Compliance with this Code of Conduct is required of all program participants. Failure to comply, at the discretion of
WSU Tri-Cities, may result in dismissal from the Program. In the event of a violation, the Student’s parent or guardian
may be contacted. Program participants shall be respectful of the WSU Tri-Cities community, which includes people
with diverse backgrounds and beliefs. Conduct that is disrespectful or demeaning to others, including but not limited
to verbal or physical harassment, will not be tolerated.
The following actions are prohibited during any part of the Program: (1) Failure to adhere to all University polices,
rules, and regulations. (2) Possession, use, distribution, or being in the presence of alcohol or illegal drugs. (3) Misuse
of prescription drugs. (4) Use of tobacco products. (5) Possession or use of weapons. (6) Disorderly conduct, including
but not limited to verbal or physical harassment, misuse/damage/theft of University property and equipment, use of
video or audio recording where privacy is expected, and interaction of a sexual nature or sexually suggestive manner
with any other person. (7) Use of offensive language such as swearing. (8) Traveling outside of the designated
campus area boundary without prior permission or supervision from camp staff.
Students will be required to follow their school district dress code policy while attending this camp. Most workshops
and activities will take place indoors, however, some will require students walk to and from different buildings. In the
event that requires you to cancel your attendance to the camp, students must notify Summer Session by May 27. No
refund will be given if you cancel your attendance after May 27. Contact information is at the bottom of the last page.
Please do not email or scan any forms attached to this registration.
GEAR UP STUDENTS: See the GEAR UP site manager at your school for instructions.
Mail your completed registration form with a check (made payable to Washington State University Tri-Cities) to:
WSU TRI-CITIES SUMMER CAMPS
2710 CRIMSON WAY
RICHLAND, WA 99354
SPACE IS LIMITED AND PRE-REGISTRATION IS REQUIRED!
PAGE 4 COUGAR DISCOVERY REGISTRATION FORM
I, __________________________________________(student), agree to comply with the above expectations. I understand
that failure to comply may result in being removed from the camp with no refund allowed.
(BOTH SIGNATURES ARE REQUIRED.)
__________________________________________________________________ ________________________________
Signature of Student Date
__________________________________________________________________ ________________________________
Signature of Parent/Guardian Date
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5. PAGE 5 COUGAR DISCOVERY REGISTRATION FORM
WASHINGTON STATE UNIVERSITY (WSU)
RELEASE AND ASSUMPTION OF RISK
For Parent or Guardian Claims of Participants Under 18 Years of Age
PARENT OR GUARDIAN CONSENT
I am the parent or guardian of the child, a minor under the age of eighteen (18) legally incompetent to contract,
whose name is set forth below. I certify that I am authorized to make decisions on that person’s behalf. I understand
that there are risks in participating in the educational activities associated with Cougar Discover summer academic
camps at Washington State University (WSU) Tri-Cities. In consideration for and as a condition of the above listed
students being allowed to participate in this voluntary activity, I agree to take full responsibility for any and all risks
that exist including the risk of death or injury to my student or loss or damage to my property. I understand that
there may be risks that WSU cannot predict or foresee, and I also assume full responsibility for those risks. Risks in
participating in the Cougar Discovery summer academic camp activities which may be conducted indoors or
outdoors include, but are not limited to, serious neck and spinal injuries which may result in complete or partial
paralysis and/or brain damage; serious injury to virtually all bones, joints, ligaments, muscles, tendons, and other
aspects of the muscular skeletal system; serious injury or impairment to other aspects of the child’s body, general
health, and well-being, and/or death. I also recognize that there are both foreseeable and unforeseeable risks of
injury or death that may occur that WSU cannot specifically anticipate and list here.
PARENT OR GUARDIAN’S RELEASE OF CLAIMS AND LIABILITY
I am responsible for and allow the person whose name is set forth below to participate in Cougar Discovery summer
academic camp on WSU property. I personally and voluntarily consent to the involvement of the person whose name
is set forth below. I release program sponsors individually and in their roles as employees or agents of WSU, their
heirs and assigns; the state of Washington; the Regents of WSU; WSU; any subdivision or unit of WSU, its officers,
employees, and agents, as well as their heirs or assigns; from any claims I may have by virtue of my role as parent
or guardian and from all liability derived from my status as parent or guardian. This includes all liability, claims, costs,
expenses, injuries and/or losses which I may sustain, derived from my role as parent or guardian, as a result of the
participation of the below named child in the above named event.
I have carefully read this document, understand its contents and am fully informed about this program and
circumstances. I am aware that this document is a contract with WSU and program sponsors. I sign it freely and
voluntarily.
DATED THIS _____________ DAY of ___________________________________________, 2016.
___________________________________________________ _________________________________________________
Name of Parent or Guardian (Printed) Signature
___________________________________________________ _______________________/_________/_______________
Name of Minor (Printed) Minor Date of Birth
___________________________________________________ _________________________________________________
Witness’s Name (Printed) Witness’s Signature
Note: Witness need not be a notary or have an official position. They may be spouses, friends, or co-workers.
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6. Choosing Your Major! *REQUIRED
Exploring Your Career Interests *REQUIRED
Engineering (Civil, Electrical, or Mechanical)
tricities.wsu.edu/engineering
Computer Science
tricities.wsu.edu/computerscience
Business Administration
tricities.wsu.edu/business
Nursing
tricities.wsu.edu/nursing
Education
tricities.wsu.edu/education
Digital Technology & Culture
tricities.wsu.edu/dtc
Environmental Science
tricities.wsu.edu/environmentalscience
Humanities & Social Sciences or Psychology
tricities.wsu.edu/humanities
tricities.wsu.edu/psychology
_______
_______
_______
_______
_______
_______
_______
_______
Students will have the opportunity to choose a “major” and attend an engaging workshop series each day taught by
experts in that field of study.
STUDENTS: Select your first choice by placing a number 1 on the left column beside the name. Then, select your
second choice by placing a number 2 in the same manner. If your first choice is not available, you will be placed in
your second. Looking for more information about the majors? Visit the websites corresponding with each program.
Students will also have the opportunity to explore different careers during the Career Exploration sessions. Industry
professionals from the local region will be invited to present and offer unique insights on their career.
STUDENTS: Please select from any of the majors listed above and explain which careers particularly interest you.
For example, if you are interested in Business you can specify marketing, accounting, finance, etc.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
WSU Tri-Cities Summer Programs
2710 Crimson Way
Richland, WA 99354
Main Line: (509) 372-7174
Becky Chamberlain
Director of Summer Session
(509) 372-7174
becky.chamberlain@tricity.wsu.edu
Timothy Palacios
Summer Session Coordinator
(509) 372-7206
timothy.palacios@tricity.wsu.edu
PAGE 6 COUGAR DISCOVERY REGISTRATION FORM
Students will
be emailed their
camp schedule at
least one week prior
to June 27.
A copy will also
be available on
Day 1.

7. Cougar Discovery & The B‐Reactor Tour
April 11, 2016
Dear Cougar Discovery Parents/Guardians,
We hope you and your student are excited about the opportunity for Cougar Discovery
participants to experience visiting the B-Reactor National Historic Landmark! The Manhattan
Project has issued the attached Parent Packet release form. Although there is no minimum age
for these tours, it is important to note that all visitors under the age of 18 must have a parent or
legal guardian sign the tour release form agreeing to the set forth conditions.
Washington State University Tri-Cities wants to make you aware that some of the conditions the
Manhattan Project has specified in their release forms conflict with the coordination efforts
involved with your student’s participation in Cougar Discovery. As a result, we have outlined
specific instances where expectations on their forms have needed to be modified. The Manhattan
Project understands the need for these changes and approves of the following items being upheld
as exceptions to their policies while partnering with Cougar Discovery:
 Please sign and return this form and the release and consent form (very last page) as
an attachment to your Cougar Discovery Student Registration Packet.
 Parents/Guardians will not be allowed to attend the B-Reactor tour as part of their
student’s participation in Cougar Discovery. WSU Tri-Cities will provide
transportation for students to and from the site. Our camp staff/counselors will
accompany them in order to ensure compliance with all rules.
 This form along with its attachments must be signed and returned to Cougar
Discovery before the actual start of the camp (beginning June 27).
 Where the release and consent form (very last page) asks to indicate a date of the
tour, please leave the space blank. Cougar Discovery will project at a later time the
exact date, either June 28 or June 29, when your student will go on the tour.
Students can check their camp schedule released via email one week prior to camp.
If you have any questions about the above expectations from Cougar Discovery that are not
outlined or controvert what is stated in the attached forms issued by The Manhattan Project,
please contact Summer Session at WSU Tri-Cities by phone (509) 372-7206 or by email at
summer@tricity.wsu.edu.
With your signature, you agree to having read and understand all aspects of this notice.
_______________________________________________ _____________________________
Parent/Guardian Signature Date

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