BYP Summer Camp 2014 Registration Form

Biomedical Youth Summer
Camp 2014
Participant Registration Form
The Biomedical Youth Program (BYP) at the Faculty of Medicine, University of
Manitoba aims to promote science education and literacy among youth, particularly
those from underserved, inner-city communities. The Biomedical Youth Summer
Camp is an outreach initiative of the BYP, where participants carry out hands-on
science activities encompassing topics from Medicine, Medical Rehabilitation,
Pharmacy, and Basic Sciences.
The Camp will be held daily from July 21-25, 2014 from 10:00 a.m. – 2:00 p.m at the
University of Manitoba Bannatyne Campus. Participation in the Camp is free;
however, participants and guardians will be responsible for lunch, travel, and
associated expenses. Participants attending the Camp can be dropped off at John Buhler
atrium (- door to right of Brodie entrance - 727 McDermot Ave.) at least 20 minutes
prior to the start of the day. Parents/guardians are expected to promptly pick up/signout their child/ren.
Registration for all interested participants commences on May 15, 2014. The deadline
for all registration forms is June 27, 2014. Confirmations of participant registration in
the Camp will be sent out via e-mail in early July. Any questions regarding this form or
the Camp in general can be directed to [email protected].
Please return the completed registration form to:
Biomedical Youth Program
College of Medicine, Faculty of Health Sciences
Dept. of Community Health Sciences
Rm. S113 – 750 Bannatyne Ave.
Winnipeg, MB
R3E 0W3
Fax: 204-789-3905
1|Biomedical Youth Summer Camp 2014 – Registration Form
Participant’s Information (Please TYPE in the following fields)
Last Name:
Age:
Grade Completed (as of July 2012):
School:
First Name:
Gender:
Contact Information
Mailing Address:
City:
Postal Code:
First Name:
Province:
Guardian’s Information
Name:
Relationship to Participant:
Home Phone Number:
E-mail Address:
Daytime Phone Number:
Other Information
Please respond to the following questions in the space provided:
How is your son/daughter being picked up from the Camp? By whom?
(NOTE: The BYP is not responsible for providing transportation for Camp participants)
___________________________________________________________________________
Are you a member of the Canadian Indigenous community? (Voluntary self-identification)
___________________________________
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Health Information
Check all that apply. More information allows the BYP to better meet the needs of your child.
My child ...
Has up-to-date vaccinations
Has dietary concerns
Carries an Epipen
Requires medication during Camp hours
Has asthma
Carries an inhaler
Wears a Medical Alert Bracelet
Has allergies
Has a Disability
If any of the above boxes were checked off, please provide us further information so we can
better meet the needs of your child (eg., if your child has dietary concerns, please specify and
to what severity).
3|Biomedical Youth Summer Camp 2014 – Registration Form
Waiver, Release, Indemnity, Acknowledgment of Risk, and
Conditions of Enrolment
As parent and/or legal guardian for my child, _________________________ [print name of
child]
1. I hereby authorize the Biomedical Youth Program to take photographs of my child
named in this application (“my child”) during Camp activities, and to display and
otherwise use these photographs without charge solely for the purpose of promotional
material in connection with the Biomedical Youth Program.
2. I also understand that injuries can arise by accident from the very nature of the
Biomedical Youth Program’s activities, and I hereby release and waive all rights to any
claim or action against the Biomedical Youth Program its employees and volunteers,
arising from injury, loss or damage to my child or to my child’s property except where
such injury, loss or damage is caused by negligence.
3. I hereby authorize the Biomedical Youth Program, its employees and volunteers to seek
emergency medical assistance and treatment for my child named in this application
(“my child”) if the parents/guardians or emergency contact cannot be contacted.
________________________________
Signature of Parent/Legal Guardian
________________________________
Printed name of Parent/Legal Guardian
________________________________
Date
4|Biomedical Youth Summer Camp 2014 – Registration Form

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