ACORN Summer Research

Camper Information

First Name

Middle Name

Last Name

Birthdate

Email Address

Cell Phone

Mailing Address

Country

Street

City

Region

Postal Code

Will you start as a student at Alma College student in the upcoming fall semester?

Yes

Academic Interest 1

Academic Interest 2

Parent/Guardian Information

Relationship

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Email

Parent/Guardian Phone

Should the above person be the primary Emergency Contact

Emergency Contact

Relationship

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Email

Parent/Guardian Phone

Medical and Health Information

Please note Alma College faculty/staff cannot administer medications as we do not employ medical staff for camps.

Is this participant having any of the following problems

Seizure/Convulsions

Asthma

Diabetes

Spinal/Head Injury

Heart Condition

Other Medical Conditions

None

Please detail other medical condition(s)

Please list any medication, dosage, treatment that the participant takes

Please note that medication must be in their original package/container with the name of the person who is taking them.
**Our staff can store but not administer medications to participants.

If the participant's physical activity needs to be restricted due to physical limitation or illness, please explain:

Please explain any special considerations or conditions, such as: Health/Behavioral/Emotional or Allergies/Fainting/Sleepwalking, etc:

Dining & Allergies

Do you have allergic reactions to any foods?

Yes

Are your allergens airborne?

Yes

Does cross-contamination trigger your allergen?

Yes

Do you carry an epi-pen?

Yes

Please tell us how you will transport this around campus should you require it:

Special dietary request (check all that apply):

Gluten

Diary

Peanut

Tree nut

Fish

Crustacean

Soy

Sesame

Corn

Other

If Other, please explain:

Please add any information pertaining to your dietary and/or allergen concerns while on the Alma College campus that you feel is important we know about.

If you would like to discuss your child's dietary needs over the phone with dining services, please list common times/days you are available.

Please have your student/child speak with a manager or chef during their meal time if they have any questions.

Housing Information

Is there someone else attending this camp that you would like to room with?

Name of Person you would like to room with

Do you require any housing accommodations?

Please list accommodations

While we can not guarantee to be able to meet your request, we will do our best to accommodate you.

Release of Liability, indemnification & Media Agreement

I, the undersigned parents/guardian, give permission for my child to attend and participate in the camp at Alma College. I understand this event will take place at Alma College and my child will be under the supervision of Alma College designated individual(s). I hold the college and all its staff and volunteers harmless for any injury or incident involving my child.

In the event of any emergency, I authorize Alma College to secure from any licensed hospital, physician and/or medical personnel any treatment deemed necessary for me or my minor child/ward's immediate care and agree that I will be responsible for payment of any and all medical services rendered. I understand that this authorization includes transporting my child by ambulance if necessary to the nearest medical treatment facility if I am unable to be reached first.

It is understood that the signature on this consent form by one parent or guardian implies the consent of the other. By typing below I am stating the above information is complete and truthful.