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STUDENT INFORMATION SHEET
Sunday, July 17 – Thursday, July 21, 2011
Application deadline for ALL applications is Friday, June 3, 2011
Applicant must have a minimum 2.25 GPA.
Applicant must have taken the ACT/SAT test at least once and submit their scores.
Applicant must submit at least 1 letter of recommendation from a school official.
$25.00 participation fee
SECTION 1: PERSONAL DATA
PLEASE PRINT OR TYPE
Student's Name___________________________________________________________________ School _________________________________________________________________________ Classification________________ Email address ____________________________________________ GPA __________________ Address_______________________________________ Phone (____)______________________ City_______________________ State______________ Zip _________________________ Student plans to attend _____________________________________University/College/Vocational. What are your future plans in respect to your career? _______________________________________ _________________________________________________________________________________ Has either of your parents completed a four year degree? Yes ______ No ________ SECTION 2: ACHIEVEMENTS
On a separate sheet, describe your achievements and financial needs using the categories below.
Academic Awards, Honors & Achievements SECTION 3: WRITTEN COMMUNICATION SKILLS
On a separate sheet, type a paragraph (200 - 250 words) on, "The importance of a college,education."
SECTION 4: PLEASE SUBMIT A COPY OF YOUR OFFICIAL TRANSCRIPT.
_______________________________________________________ Signature of Counselor or School Official _____________________________________ __________________ SECTION 5: ACADEMIC RECOMMENDATION
Please include at least one letter of recommendation.
To return the application or for additional information, you may contact the Summer Institute
1100 Henderson Street
HSU Box 7820
Arkadelphia, AR 71999-0001
Students will be notified if they are selected to participate.
GUIDELINES FOR SUMMER INSTITUTE PARTICIPANTS
I, ______________________________________________, agree to the following guidelines:
1. Participants will be actively involved in ALL scheduled activities unless a medical excuse is provided. 2. Participants will eat breakfast, lunch and dinner at the scheduled times and locations – these meals are not optional. 3. Participants will be on time and in attendance for all sessions. 4. Participants will be respectful to all presenters during each session. Sleeping and talking will not be tolerated. 5. Visitors and participants of the opposite sex are NOT allowed in dorm rooms at any time. Members of the opposite sex may visit in the lobby of the residence hall. 6. Participants must be in their rooms and lights out no later than 12:00 midnight each night. Room checks will be
7. If participants drive to Henderson State University, vehicle keys must be turned in to the program director. In case of an emergency requiring the use of a vehicle, please contact the program director. All contact information for the program director will be given upon your arrival. 8. Participants are to conduct themselves as young ladies and gentlemen at all times. 9. Participants must be dressed appropriately at all times. Males: No sagging pants, head rags or caps etc.
Females: No short skirts or short shorts, halter tops or excessively tight or revealing clothing will be allowed
at any time.
10. Participants are urged to bring as little electronic equipment as possible to campus. All cell phones, paging devices, IPods and mp3 players, etc. must be left in participants’ rooms at all times. Participants are responsible for locking their rooms at all times and securing all of their personal property while they are in attendance. Henderson State University will not be responsible for any lost or stolen personal property. This document gives permission for the above-named student to participate in all activities for prospective college students from July 17, 2011 to July 21, 2011. Permission is also granted for the Summer Institute staff members and university personnel to transport the above-named student to and from these activities upon his/her arrival at Henderson State University. I am aware and understand the guidelines of Summer Institute and realize that failure to comply with these guidelines will result in immediate expulsion from the program. I have been well advised of the nature of the activities my child will be engaged in during the Summer Institute, and I acknowledge and understand that accidents may happen. I knowingly waive any claim against Henderson State University for injuries my child may suffer whether from simple or gross negligence, other than those arising from willful acts of the sponsors, counselors, or agents of the University from liability whatsoever for such injuries. I certify that I am legally responsible for the student for whom this release is submitted.
Parent/Guardian Signature: ____________________________________________________________
Printed Name: ________________________________________________________________________
Relation to Participant: _________________________________________________________________
Participant’s Signature: __________________________________________ Date_______________
Printed Name: _______________________________________________________________________
Home Phone: _________________________ Cell Phone: _________________________________
Medications may only be administered by an employee of the Summer Institute as directed by the Program Director
and only if this medication consent form is not fully completed. Medications will NOT be administered to the camper
if the form is not completed. The following medications will be administered as needed ONLY if initialed by
Other ______________________________________________________ I know of no medical or other reason why my child should not participate in the Summer Institute. Please legibly print any known allergies: Food Insect bites / stings This medical history/medication consent form is correct as far as I know. I understand that both forms must be filled out
COMPETELY in order for my child to receive treatment at the HSU camp. I understand that in the case of an emergency,
every effort will be made to contact a parent/guardian prior to treatment. If a parent or guardian cannot be reached, however,
and the situation requires immediate emergency attention as determined by camp staff, I hereby authorize representatives of
the camp to obtain emergency treatment for my child as deemed necessary by representatives of the camp. I agree to the
release of any records necessary for treatment or referral of the minor child.
Arkansas State Law requires parental authorization to administer any prescription medications brought by camper; prescribed
medication MUST be in its original container with the pharmacy label showing number, patient name, date filled, physician
name, name of medication, and directions for use.
I authorize the camp health supervisor to administer to my child any prescribed medications being brought to camp.
NON-PRESCRIPTION MEDICINES: I authorize the health care supervisor or designated First Aider to administer the
non-prescription medications that I have initialed above in brand name or generic form if necessary for camper’s comfort.
Any medications not initialed by parent/guardian will NOT be administered to camper at any time.
I certify that I am legally responsible for the student for whom this release is submitted.
Parent/Guardian Signature _____________________________________________________ Date__________________
Participant’s printed name__________________________________________________________ In consideration for receiving permission for my child to participate in the Henderson State University Summer Institute 2011, I, the undersigned, execute this Covenant Not to Sue and Agreement to Hold Harmless voluntarily to bind myself, my child, my family and heirs. I hereby RELEASE, WAIVE, DISCHARGE, AND COVENANT NOT TO SUE, AND AGREE TO HOLD HARMLESS for any and all purposes Henderson State University, the Board of Trustees of Henderson State University, and their officers, servants, agents, volunteers, or employees (herein referred to as RELEASEES) FROM ANY AND ALL LIABILITIES, CLAIMS, DEMANDS, OR INJURY, INCLUDING DEATH, that may be sustained by my child while he or she is a participant in the Summer Institute, while traveling to or from the Summer Institute or while on the premises owned or leased by RELEASEES, including injuries sustained as a result of the negligence of RELEASEES. I know of no medical reason why my child should not participate in the Summer Institute. I am fully aware that there are inherent risks involved with participating in the Summer Institute, including but not
limited to property damage and serious personal injury to me and my child, including death, and I choose to
voluntarily allow my child to participate in the activity with full knowledge that doing so may be hazardous to my
child and his/her/my property. I VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR ANY RISKS
OF LOSS, PROPERTY DAMAGE OR PERSONAL INJURY, INCLUDING DEATH, that may be sustained
by my child as a result of participating, including injuries sustained as a result of the negligence of the releases.
1. That participation in Summer Institute may subject my child to potentially hazardous activities including but not limited to
automobile travel and overnight accommodations in university residence halls.
2. I give permission for my child to participate in any trips planned and taken as a part of the Summer Institute I understand
and agree that these trips may involve transportation by automobile.
3. I acknowledge that the use of alcohol or drugs is strictly prohibited during Summer Institute. I understand and agree that
my child will not use or be under the influence of alcohol or any drug while participating in Summer Institute. I agree that
my child’s failure to comply will result in his/her being dismissed from the Summer Institute immediately. In the event that
my child is dismissed from Summer Institute, I will be responsible for arranging my child’s transportation home at my own
4. I have reviewed the tentative schedule for Summer Institute. The Releasees have provided me with sufficient information
regarding the activities my child will be engaged in during the Summer Institute.
5. I understand that Henderson State University and the other releasees may not maintain any insurance policy covering any
circumstance arising from my child’s participation in the Summer Institute. As such, I am aware that I should review my
child’s personal insurance coverage.
6. If my child should suffer an injury or illness while at the Summer Institute, I authorize the Releasees to use their discretion
to transport or to have the minor child transported to a medical facility and obtain medical treatment. I understand that I will
be financially and legally responsible for any medical care provided to my child and will hold the Releasees harmless.
It is my express intent that this Covenant Not to Sue and Agreement to Hold Harmless shall bind my child, the members of my child’s family, my family and spouse, if I am alive, and my and my child’s heirs, assigns and personal representatives, if I or my child is deceased, and shall be governed by the laws of the State of Arkansas. Nothing in this Covenant Not to Sue and Agreement to Hold Harmless shall be deemed to waive the sovereign immunity of Henderson State University. Pursuant to A.C.A. §19-10-204, the Arkansas State Claims Commission shall have jurisdiction over any dispute regarding my participation in this activity and this Covenant Not to Sue and Agreement to Hold Harmless. Summer Institute (continued) I agree that I will pick up or arrange for transportation for my child at the end of the scheduled program for Summer Institute as Releasees will PROVIDE NO SUPERVISION OF STUDENTS AFTER THE SUMMER INSTITUTE dismisses. I acknowledge and agree that the Releasees reserve the right to dismiss any student who fails to comply with the Summer Institute Guidelines, the instructions of the Program Director, or other representative of the Releasees. Program disruption or disrespectful behavior is grounds for dismissal at any time. I grant permission to the Releasees to release personally identifiable information about my child in order to publicize his or her participation in the Summer Institute and to otherwise promote the Summer Institute. I grant the Releasees the unrestricted right and legal permission to use, re-use, publish, and republish any image, photograph and/or likenesses of my child, in whole or in part, in any and all media for any lawful purpose. I certify that I am legally responsible for the participant for whom this release is submitted. In signing this Covenant Not to Sue and Agreement to Hold Harmless, I acknowledge and represent that I have read the
foregoing Covenant Not to Sue and Agreement to Hold Harmless, I have had the opportunity to ask questions, I understand it
and sign it voluntarily as my own free act and deed; no oral representations, statements, or inducements apart from the
foregoing agreement that has been reduced to writing have been made. I execute this document for full, adequate and
complete consideration fully intending to be bound by the same, now and in the future.
SIGNED this day of , 20____.
Relationship to Participant: ______________________
Parent/Guardian Home Phone: ____________________Mobile Phone: _____________________
Participant Signature: _____________________________________________
Printed Name: _________________________________________________
In the event we cannot reach you in an emergency, please provide another trusted contact person:
Emergency contact name: _________________________________________
Relationship to student: ________________________________________
Mobile phone number:_____________________
Home phone number:___________________________
Please return pages 1-6 of the Summer Institute application packet complete with all signatures and
requested documents by June 3, 2011. You may keep pages 7 and 8 for your reference.
Ms. Wanda Harris
Henderson State University
HSU Box 7820
Arkadelphia, AR 71999-0001
The following is a sample schedule to give you an idea of the activities in which the student will be involved. A confirmed schedule for this year will be posted on the website and available prior to arrival by postal or electronic mail upon request. Summer Institute Sample Schedule
Registration & Move-in
Ice Breakers & Team Builders
Movie & Pizza
HSU Campus Tour
Discuss Group Project
Participants are divided into teams. Each team will complete a project that reinforces relational concepts
learned in the sessions. The final projects will be presented at the closing ceremony.
“Show Me the Money” - Financial Aid Tips
Health and Wellness
Expectations of a College Professor
Cook out on the grounds
Group Project and game activities in the dorm 7:30pm-until
Career Path Explorations
Evening out in Little Rock
1:00pm until 8:00pm
Cultural and social educational activities
Group Project Completion
Dress for closing ceremony
Parents’ / Participants’ Reception
To Parent(s)/Guardian(s): Complete this section and give this form (FORM 2) and a copy of your completed CAMPER HEALTH HISTORY FORM (FORM 1) to your child’s health-care provider for review. Developed and reviewed by: American Camp Association, Dates wil attend camp: from ______________to_____________ American Academy of Pediatrics Council on School Health, & Camp