PROGRAM INFORMATION
Special Note: You will need a program code to complete your registration. The program code is a series of two letters followed by six numbers (for example SA523726). You can obtain the program code from a school counselor or graduation specialist.
Please enter the program code for the credit recovery program you would like to attend:
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STUDENT'S INFORMATION
Student's Last Name:
Student's First Name:
Student's Date of Birth (MM/DD/YYYY):
Student's ID #:
Student's Gender:
(Please Select)
Male
Female
Other
Prefer Not to Say
Student's School (for 2023-24):
(Please Select)
Beekman
CAK12O
Eastern
Everett
Lansing Learning Hub
Lansing Tech.
Other
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STUDENT ACKNOWLEDGEMENTS
I understand that it is a privilege to be invited to attend this unique learning opportunity and that the singular goal of this experience is to assist me in accomplishing my goal of graduating high school. As such, while at the Ebersole Center, I will act with integrity and adhere to the highest standards of personal behavior including (but not limited to) the following: I commit to treating others with respect and dignity;
I commit to speaking with honesty and care; I commit to taking responsibility for my learning and behavior; I commit to actively seeking clarification and support from others; and I commit to working diligently to accomplish my goal(s).
Initial here to acknowledge that you have read and agree to adhere to the code of conduct and commitment statement detailed above.
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STOP. WAIT. Special Note. Only continue completing this form if this is your first time attending the Ebersole Center during the 2023-2024 academic year. If you have already attended an overnight Ebersole Center event this year, we will already have your information on file and there is no need to complete the rest of this form. Please skip to the bottom, answer the security question, and hit "Submit".
PARENT'S INFORMATION
Parent/Guardian's Last Name:
Parent/Guardian's First Name:
Parent/Guardian's Primary Phone:
Parent/Guardian's Email Address:
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STUDENT'S EMERGENCY CONTACTS
Special Note: We will assume that the PRIMARY Emergency Contact is the parent/guardian listed above.
(Secondary) Emergency Contact's Last Name:
(Secondary) Emergency Contact's First Name:
(Secondary) Emergency Contact's Relationship to the Student:
(Please Select)
Parent
Grandparent
Aunt/Uncle
Family Friend
Other
(Secondary) Emergency Contact's Phone:
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STUDENT'S PRIMARY MEDICAL CARE & MEDICAL INSURANCE
Does this student have a primary care doctor?
(Please Select)
Yes
No
If YES, please provide the name of this student's primary care doctor:
If YES, please provide the phone number of this student's primary care doctor:
Is this student covered by medical insurance?
(Please Select)
YES
NO
If YES, please provide the name of the medical insurance company:
If YES, please provide the phone number for the medical insurance company:
If YES, please provide the relevant medical insurance policy number:
If YES, please provide the name of the SUBSCRIBER for the medical insurance policy:
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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STUDENT'S IMMUNIZATIONS
Are all of the student's immunizations up to date?
(Please Select)
YES
NO
If NO, please initial the box below acknowledging that you understand and accept the risks to your student from not being fully immunized.
Please provide the month and year of the student's last tetanus immunization (MM/YYYY):
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STUDENT'S ALLERGIES
Is this student allergic to any food, medication, or insect stings?
(Please Select)
YES
NO
If YES, name the item(s) that this student is allergic to and indicate the reaction.
Item #1: My student is allergic to:
My student's reaction to Item #1 is:
(Please Select)
Intolerance
Anaphylaxis (requires an EPI-Pen)
Item #2: My student is allergic to:
My student's reaction to Item #2 is:
(Please Select)
Intolerance
Anaphylaxis (requires an EPI-Pen)
Other allergy related information about the student that we may need to know about:
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STUDENT'S ASTHMA
Does this student have medically-diagnosed asthma that requires you to send an inhaler to camp?
(Please Select)
YES
NO
If YES, does the student need staff help to use their rescue inhaler?
(Please Select)
YES
NO
If YES, what triggers the student's asthma?
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STUDENT'S DIET & SLEEPING HABITS
Select all that apply to this student's diet.
This student eats a vegetarian diet.
This student has a lactose intolerance.
This student has a gluten intolerance.
Any other dietary information about this student that we should know about:
Select all that apply to this student's sleeping habits.
This student is prone to sleep walking.
This student is prone to bedwetting.
This student is prone to rolling out of bed.
Any other sleep-related information about this student that we should know about:
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STUDENT'S CHALLENGES
Please share any information about physical difficulties you think are important for us to know about or that may impact this student's ability to fully participate in camp activities:
Please share any information about mental, emotional, or social difficulties you think are important for us to know about or that may impact this student's ability to fully participate in camp activities:
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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 camp. Expired prescriptions will not be dispensed.
Student's Medications:
NO, this student will not take any daily medications while at camp.
YES, this student will bring an inhaler or EPI-Pen to camp.
YES, this student will take the following daily medications while at camp.
Name of Medication #1:
Medication #1 - Amount or Dosage:
Medication #1 - Reason for Taking:
Medication #1 - Given at:
(Please Select)
Breakfast
Lunch
Dinner
Bedtime
Other
Name of Medication #2:
Medication #2 - Amount or Dosage
Medication #2 - Reason for Taking:
Medication #2 - Given at:
(Please Select)
Breakfast
Lunch
Dinner
Bedtime
Other
Name of Medication #3:
Medication #3 - Amount or Dosage
Medication #3 - Reason for Taking:
Medication #3 - Given at:
(Please Select)
Breakfast
Lunch
Dinner
Bedtime
Other
Please provide any additional medication related information about this student that you think we should know about:
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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 CAMP photo and video usage.
YES, it is alright for the Lansing School District to use CAMP photos and/or video of my student for promotional purposes through broadcast, print, and/or social media.
NO, it is not alright for the Lansing School District to use CAMP photos and/or video of my student for promotional purposes through broadcast, print, and/or social media.
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PARENT/GUARDIAN'S ACKNOWLEDGEMENTS
(A) Please initial to acknowledge that the information contained in this form is correct and accurately reflects the health status of the student to whom it pertains.
(B) Please initial to acknowledge that this student has permission to participate in all camp activities.
(C) Please initial to acknowledge that you understand the information on this form will be shared on a “need to know” basis with camp staff, and that you give permission to photocopy this form.
(D) Please initial to acknowledge that you understand that if your student needs to be sent home due to illness, injury, or disciplinary reasons, that you are responsible for picking your student up.
(E) Please initial to acknowledge that you understand that the camp has limited health care onsite and that staff will call the indicated parent/guardian in an emergency and/or if your student is unable to continue because of injury or illness.
(F) Please initial to acknowledge that you give permission to the physician selected by the camp to order x-rays, routine tests, and treatment related to the health of your student in emergency situations.
(G) Please initial to acknowledge that if you cannot be reached in an emergency, you give your permission to the physician to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for this student.
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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