Summer Academy Application June 6-9, 2016

Transcription

1 Summer Academy Application June 6-9, 2016 Application deadline: May 20, 2016 **Please complete the application in black or blue ink ** Thank you for your interest in the SCCC/ATS summer academies. Complete this application and send the form and payment to the address below. The cost of the summer academy is $100. A non-refundable payment of $20 is due with this application. Bring the remaining $80 with you at check-in on June 6. All sections of this application must be completed, including the Student Health and Emergency Form and the Tuberculosis Screening Questionnaire. After we receive your application, we ll you with more information. An academy schedule and a checklist to help you get ready are available on the academy website at If you have questions, contact Sharon Nickelson at or sharon.nickelson@sccc.edu. Send the application and a check or money order for $20 to: Seward County Community College/Area Technical School Attn: Sharon Nickelson P.O. Box N Kansas Ave Liberal, KS SECTION I: CHOOSE YOUR ACADEMY (CHOOSE ONLY ONE.) Food Science Sustainable Agriculture Engineering SECTION II: PERSONAL INFORMATION Student Name: Student Address: Student Sex: Male Female Age: of Birth: Grade Level: (grade you will be entering) Year Graduating: School District: School Name: Do you have any special food requirements (such as vegetarian, food allergies, kosher, halal, or others)? Yes or No If yes, what requirements? Parent/Guardian Name: Parent/Guardian and Phone: SECTION III: KANSAS MIGRANT EDUCATION PROGRAM Are you Kansas Migrant Education Program eligible? Yes No If yes, complete this section. COE# MEP # School Phone: School Contact: Position:

2 SECTION IV: INSURANCE INFORMATION Attach a copy of your health insurance card, if available. SECTION V: STUDENT HEALTH AND EMERGENCY FORM Complete the attached Student Health and Emergency Form, including the meningococcal meningitis vaccination information. If vaccination information is not available, or you choose not to receive the vaccination, then sign the waiver on the second page of the form. SECTION VI: TUBERCULOSIS SCREENING QUESTIONNAIRE Complete the attached Tuberculosis Screening Questionnaire. Note that medical testing may be required. If medical testing is required, all testing must be completed before participating in the academy. SECTION VII: LIABILITY RELEASE I (parent or guardian) release Seward County Community College/Area Technical School from liability if any injury or sickness should occur to my son or daughter while attending the summer academy or participating in academy activities. Parent/Guardian initial here SECTION VIII: INFORMATION RELEASE I (parent or guardian) give Seward County Community College/Area Technical School permission to use my son or daughter s name, photograph, and other general information for promotional purposes and/or for release to news media. Permission is not required for camp participation. If you do not wish to give permission, please check No and initial where indicated. Yes No Parent/Guardian initial here SECTION IX: RULES OF CONDUCT I (student) understand that I must follow the Seward County Community College/Area Technical School academy rules of conduct. Unacceptable behaviors include, but are not limited to, using or possessing alcoholic beverages, tobacco products (including vapes and e-cigarettes), illegal drugs, firearms or other weapons; verbally or physically harassing others; entering the living areas of the opposite sex; damaging property; endangering the safety of others; theft; disruptive behavior; leaving the dorms after hours; and leaving campus without permission. Academy leaders may also have other requirements. I understand that a violation of conduct rules could result in disciplinary action and being sent home without a refund. Student initial here Parent/Guardian initial here SECTION X: SIGNATURES I hereby state that, to my knowledge, all information contained in this form is accurate. Print Name Camp Participant Sign Name Camp Participant _ Print Name Parent/Guardian _ Sign Name Parent/Guardian _

3 SEWARD COUNTY COMMUNITY COLLEGE/AREA TECHNICAL SCHOOL SUMMER ACADEMY STUDENT HEALTH AND EMERGENCY FORM The following information is a confidential health/emergency record. It will be kept on file and will not be released without the knowledge and/or written consent of the student. This information will be used to provide healthcare to the student. Personal Information: NAME DOB SEX: M F PH # (Print-Last, First, MI) HOME ADDRESS (street address) (city/state/zip) Personal Medical Information: ALLERGIES: Medication Food Seasonal Other No known Allergies Medications currently taking: (include prescription, birth control, over the counter, herbal) Chronic Health Conditions (Please circle those that apply): ADHD, Anemia, Seizure Disorder, Depression, Diabetes, Disability/handicap, Hearing loss, Eye disease, Heart disease, High blood pressure, Stomach problems, Sickle cell anemia, Sinus problems, Skin problems, Other (please list any other chronic health condition not mentioned above Emergency Contact Information: If a medical emergency, life-threatening situation or missing student report should occur, the following individuals may be contacted and medical information regarding the student s condition may be shared. Person to notify in case of an emergency:relationship Ph#: Home Cell Work Alternate Person: Relationship Ph#: Home Cell Work REQUIRED MENINGOCOCCAL MENINGITIS VACCINE (OR signed waiver on the following page): One (1) meningococcal meningitis vaccine given at age 16 or older. If a vaccination was received prior to age 16, a booster shot is needed. I have received the meningococcal vaccine: received Name of Provider (or attached copy of meningococcal vaccine verification) Provider Phone # Address of Provider _ Signature of Provider _ Signature of Student _ Signature of Parent (If student is under 18 years of age) City, State, Zip

4 SEWARD COUNTY COMMUNITY COLLEGE/AREA TECHNICAL SCHOOL MANDATORY MENINGOCOCCAL VACCINE TRACKING In accordance with Kansas State Law HB-2752 Under Kansas State Law (HB 2752), students attending the Seward County Community College/Area Technical School summer academies are required to provide written proof of documentation of meningitis vaccination or decline the vaccine in writing after reviewing the information provided that informs of the dangers of the meningococcal disease. If the student is under the age of 18, parents or legal guardians must sign the waiver below. Students who do not comply with a vaccination or a signed waiver will not be allowed to participate in the summer academies. Meningitis Health Information Facts, Policy and Waver Information To reduce the spread of bacterial meningitis, all summer academy students will be vaccinated for meningitis or sign a waiver indicating that they refuse to receive the vaccine at this time. What is meningococcal meningitis? Meningococcal meningitis is a severe bacterial infection of the bloodstream and meninges (a thin lining covering the brain and spinal cord). It is a relatively rare disease and usually occurs as a single isolated event. How is the germ that causes this type of meningitis spread? The meningococcal germ is spread by direct close contact (kissing, sneezing, coughing, sharing water bottles) with the nose or throat discharges of an infected person. Many people may carry this particular germ in their nose and throat without any signs of illness. Who gets meningococcal meningitis? Anyone can get meningococcal meningitis, but it is more common in infants, children, and young adults. College freshman who live in student housing have a slightly higher risk of getting this infection than others their age. What are the symptoms? Most individuals exposed to the meningococcal germ do not become seriously ill, some may develop a fever, headache, vomiting, stiff neck and rash. One-fourth of those who recover may have permanent damage to the nervous system. The disease occasionally causes death. How soon do the symptoms appear? After exposure, the symptoms will appear within two to ten days, but generally within five days. When and for how long is an infected person able to spread the disease? From the time a person is first infected until the germ is no longer present in nose and throat discharge the disease may be transmitted. The duration varies according to individuals and treatment course followed. What is the treatment for meningococcal meningitis? Penicillin is the drug of choice for treatment, although other antibiotics are very effective in eliminating the germ from the nose and mouth. Should people who have been in contact with a diagnosed case of meningococcal meningitis be treated? Only people who have been in close contact (household members, intimate contacts, etc.) need to be considered for preventive treatment. Casual contact as might occur in a regular classroom or office setting is not usually significant enough to cause concern. People who think they have been exposed to meningococcal infection should contact the local health department to discuss whether treatment is advised. Is there a vaccine to prevent meningococcal meningitis? Presently, there are two vaccines that will protect against several of the strains of the meningococcal germ. Is the meningococcal vaccine safe? Vaccines, like any medicines, are capable of causing problems such as allergic reactions. The risks associated with receiving the vaccine are much less significant than the risks that are associated with the disease. Some individuals may experience mild side effects which include redness or pain at vaccine site, warm to touch, and mild fever. Where can a student get vaccinated? Local health care provider or Seward County Health Department ( ) is located at 103 W 2 nd St in Liberal. WAIVER OF MENINGOCOCCAL MENINGITIS IMMUNIZATION (DOES NOT RECEIVE VACCINATION) I have chosen not to be immunized. My signature below signifies that I have received and read the material provided to me on meningitis by SCCC/ATS. Signature of Student REQUIRED if no vaccination on record Signature of Parent of Guardian, if student is under 18 years of age

5 TUBERCULOSIS SCREENING QUESTIONNAIRE (To be completed by all students before participation in SCCC/ATS summer academies.) Name: Student Last Name First Name & MI of Birth Phone Number (cell or home) ABOUT THIS FORM: Tuberculosis, also known as TB, is a bacterial infection that attacks the lungs and, sometimes, other parts of the body. It is spread when someone infected with the disease coughs or sneezes and the bacteria is inhaled by someone nearby. SCCC/ATS requires ALL summer academy participants to complete a Tuberculosis Screening Questionnaire, per Kansas Statute KSA 2009 Supp to aid in prevention and control of tuberculosis. Turn in this form with your application. If further testing is required, the process could take up to 4 weeks to complete. DO NOT WAIT UNTIL THE LAST MOMENT. For additional information on TB: PLEASE CIRCLE YES OR NO TO THE FOLLOWING QUESTIONS: 1. Have you ever had a tuberculosis (TB) test that was positive?... YES NO 2. Have you ever received the BCG vaccine, which is given outside the United States, to prevent tuberculosis (TB)?... YES NO 3. Have you ever been in contact with anyone who was sick with tuberculosis (TB)?... YES NO 4. Were you born in a country not in the list below? (Country of birth).... YES NO 5. Have you ever spent more than 3 months in a country not on the list below?. YES NO Please list the country. LIST OF EXEMPT COUNTRIES WITH LOW INCIDENCE OF TB (Defined by the Kansas Department of Health & Environment) Albania Canada Germany Nauru Sweden American Samoa Chile Greece Netherlands Switzerland Andora Costa Rica Grenada New Zealand Turks & Caicos Islands Antigua & Barbuda Cyprus Hungary Norway United Kingdom of Great Australia Czech Republic Iceland Saint Kitts & Nevis Britain & North Ireland Austria Denmark Ireland Saint Lucia United States Virgin Islands Bahamas Dominica Italy Samoa United States of America Barbados Fiji Jamaica Slovakia Wallis & Futuna Islands Belgium Finland Luxembourg Slovenia British Virgin Islands France Malta Spain IF YOU ANSWERED YES TO ANY OF THE ABOVE QUESTIONS, YOU ARE REQUIRED TO PROVIDE DOCUMENTATION OF FURTHER TESTING AND EVALUATION BY A HEALTH CARE PROVIDER. 1. You will be required to undergo a TB blood test instead of a TB skin test, if you: Were born in a country not on the above list. Have received the BCG vaccination. 2. If you have had a past positive TB test, you will need to present documentation of a chest x-ray within the last year or obtain one through a healthcare provider and have results submitted and documented before the first day of class. 3. If you have received prior treatment for active TB disease, you will need to provide proper documentation of such treatment before the first day of class. All tests may be obtained at the Seward County Health Department, 103 W 2 nd St, Liberal, KS Or check with your local health care provider. If none of the above applies, please sign below and send this form in with your summer academy application. Student Signature If a student is under the age of eighteen (18), signature of a parent or legal guardian: Parent or legal guardian s signature To the best of my knowledge, the information provided above is true and complete. Any student who is not in compliance with the requirements shall not attend the SCCC/ATS summer academies until the student is compliant per Kansas Statute KSA 2009 Supp