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Directions:  Thank you for your interest in the Ebersole Institute's Winter/Spring 2023 semester-long program.  By completing this form, you are one step closer to taking advantage of this exciting and dynamic learning opportunity.  Please fully complete, and submit, the registration form below.  Should you have any questions or concerns please do not hesitate to contact me at 517-755-5001.

With gratitude and appreciation, Ben Botwinski (Ebersole Director)



Ebersole Institute's Semester-Long Program Registration


PART I: STUDENT'S INFORMATION
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PART II: STUDENT'S EMERGENCY CONTACTS
Special Note: We will assume that the PRIMARY Emergency Contact is the parent/guardian listed above.
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PART III: STUDENT'S PRIMARY MEDICAL CARE & MEDICAL INSURANCE
Help for If YES, please provide the name of the SUBSCRIBER for the medical insurance policy: The SUBSCRIBER is the individual who's name the medical insurance is under. This is usually the person who's name is on the medical insurance card.
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PART IV: STUDENT'S IMMUNIZATIONS
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PART V: STUDENT'S ALLERGIES
If YES, name the item(s) that this student is allergic to and indicate the reaction.
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PART VI: STUDENT'S ASTHMA
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PART VII: STUDENT'S DIET & SLEEPING HABITS
Select all that apply to this student's diet.
Select all that apply to this student's sleeping habits.
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PART VIII: STUDENT'S CHALLENGES
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PART IX: STUDENT'S MEDICATIONS
Special Note: A Health Officer is staffed on-site at the Ebersole Center 24 hours a day when students are present. The Health Officer is responsible for distributing all medications to students.
Special Note: All medication listed on this form must come with the student. All prescriptions - including inhalers and EPI-Pens – MUST be in the original box or bottle showing the student's name, what time the medication is taken, and the dose.
Special Note: Medication is any substance a person takes to maintain and/or improve their health. This includes vitamins and natural remedies. Please provide enough of each medication to last the entire time the student will be at Ebersole. Expired prescriptions will not be dispensed.
Student's Medications:  (required)
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PART X: STUDENT'S PHOTO RELEASE
The Lansing School District occasionally use photographs and/or video of students for promotional purposes through broadcast, print, or social media. Please review the options and select one that best describes your wishes in regards to Ebersole photo and video usage.  (required)
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PART XI: PARENT/GUARDIAN'S ACKNOWLEDGEMENTS
Special Note: If there is a religious objection to consenting to receipt of emergency medical or surgical treatment, the authorized person shall submit a written statement to the effect that the student is in good health and that the person signing assumes the health responsibility for the student.
Special Note: State of Michigan licensing rule 400.11127(2) states that a camp shall maintain, in the camp, a health history statement signed by an authorized person for each student and minor staff person.
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11,500 Enrollment by 2025
85% Graduation Rate by 2025
90% Attendance by 2025