REGISTRATION FORM
Nurse Camp

June 10-11, 2009

Cost $45.00 per participant

TO BE COMPLETED BY PARENT OR GUARDIAN. PLEASE PRINT IN INK OR TYPE ONLY. FILL IN ALL SECTIONS.

Payment, in full, by check or money order must accompany this form. Return to Carteret Community College by May 1, 2009.

Important--To ensure a timely registration; please include complete information about the applicant.

______________________________________________________________________________
Last name     First name  Middle initial
 
[_] Female [_] Male  _______________________________________________________
 E-mail 
 
______________________________________________________________________________
Social Security no. (used as identification)   Birth date Age
 
______________________________________________________________________________
Home phone  Home fax
 
______________________________________________________________________________
Home address (no. and street or box no.)
 
______________________________________________________________________________
City State ZIP code   Country
 
Applicant's age (please circle one): 9 10 11 12 13 
 
T-Shirt size (please circle one) Adult S M L XL or Youth S M L
 
______________________________________________________________________________
Current School of Attendance    Grade Next Year
 
______________________________________________________________________________
Mother's/Guardian's last name  First name
 
______________________________________________________________________________
Daytime phone     Home phone
 
______________________________________________________________________________
Cell phone  Pager no.
  
______________________________________________________________________________
Father's/Guardian's last name  First name
  
______________________________________________________________________________
Daytime phone   Home phone
 
______________________________________________________________________________
Cell phone   Pager no.
 
Do you wish to be put on a waiting list if the program is full? [_] Yes [_] No
 
Fees




 
 
$45 per participant

Method of Payment
Payment, in full, must accompany this registration form. Mail registrations must be accompanied by credit card payment information.

[ _ ] Enclosed is a check or money order for the amount indicated payable to Carteret Community College.

Release (to be completed by parent[s] or guardian[s])

I, the undersigned, individually and as parent(s) and guardian(s) of
_________________________________________(student's name), a minor, ask that he/she be admitted to participate in this Nursing Camp sponsored by Carteret Community College. In consideration of such admission, I do hereby agree to release, discharge, and hold harmless Carteret Community College. The College, its officers, agents, and employees of and from all causes, liabilities, damages, claims, or demands whatsoever on account of any injury or accident involving the said minor arising out of the minor's attendance at the Nursing Camp, at Carteret Community College, or in the course of activities held in connection with the Nursing Camp.




 
 





 
 
Additionally, I/we authorize Conferences and Institutes of Carteret Community College to photograph, videotape, and/or audiotape my/our child in promotion Carteret Community College Nurse Camp summer youth program.
Both signatures requested:
 
______________________________________________________________________________
Mother's/Guardian's signature
 
______________________________________________________________________________
Father's/Guardian's signature
Participant Drop-Off and Pickup Information
 
(Student will not be released to anyone not designated by parent/guardian.)
Name of person(s) who will be dropping off and picking up student each day:
 
______________________________________________________________________________
Name   Phone number  Relationship to student
 
 
Medical Treatment Authorization




 
 
 
I hereby authorize the Nurse faculty to transport my minor son/daughter to Carteret General Hospital in the case of an emergency where medical treatment will be provided as necessary.
 
______________________________________________________________________________
 
I understand that the consent and authorization herein granted do not include major surgical procedures and are valid only during Nurse Camp at Carteret Community College. 
 
Physical conditions that the Nurse faculty should be aware of (allergies, recurring illnesses, disabilities, chronic illnesses, etc.):
______________________________________________________________________________
 
Date of most recent tetanus immunization:___________________________________________
(If more than ten years ago, a booster shot is recommended.)
 
List of all medications: ___________________________________________________________
______________________________________________________________________________
 
Food/Insect/Medication Allergies: __________________________________________________
______________________________________________________________________________
 
Carteret Community College Nurse faculty or Practical Nursing students will not dispense over-the-counter (OTC) or prescription medications to participants. Participants will be allowed to possess and take OTC and prescription medications on their own if permission is granted in writing by the parent(s)/guardian(s). Both OTC and prescription medications must be in their original containers and listed above.
In the event that an illness or injury would require more extensive evaluation, I understand that every reasonable attempt will be made to contact me. However, in the event of an emergency, and if I cannot be reached, I give my consent for physicians and staff at Carteret General Hospital to perform any necessary emergency treatment.
 

Please clearly print the following information:
 
_____________________________________________________________________________
Name of emergency contact   Phone
 
_____________________________________________________________________________
Name of family physician  Phone
 
_____________________________________________________________________________
Parent's or guardian's name (please print)
 
_____________________________________________________________________________
Parent's or guardian's signature  Date
 
 
Please indicate (if applicable) [_] HMO or [_] PPO
 
_____________________________________________________________________________
Insurance company





 
 
_____________________________________________________________________________
Insurance company address (number and street or box number)





 
 
_____________________________________________________________________________
City  State   ZIP code
 
_____________________________________________________________________________
Policy subscriber's name
 
_____________________________________________________________________________
Policy number  Group number
 

BEFORE MAILING, DID YOU REMEMBER TO:

1. Complete all information requested on the registration form, including the Release and Medical Treatment Authorization sections.

2. Sign check or money order and make payable to Carteret Community College.

3. Where appropriate, indicate all program preferences and fees.

(Complete information and payment are necessary for registration.)

PLEASE MAIL THIS FORM WITH PAYMENT TO:

Carteret Community College

Melanie Hooper, RN, BSN

Practical Nursing Program

3505 Arendell Street

Morehead City, NC 28557