Youth Innovation Program

Student Information:

Student First Name

Student Last Name

Student Email Address

Student Birthdate

Student Address

Country

Street

City

Region

Postal Code

Student's Currently Enrolled School

Student's Enrolled Grade (Fall 2022)

Learning Accommodations Needed

(i.e. closed caption, audio recording of text, larger text size, class notes, etc.):

Parent Information

First Parent Info
First Parent First Name

First Parent Last Name

First Parent Email Address

First Parent Phone

Second Parent Info
Second Parent First Name

Second Parent Last Name

Second Parent Email Address

Name of Others who will assume responsibility in absence of parent/guardian
First Name

Last Name

Phone

Relationship

Emergency contact information is different than parent information:

Yes

No

Please complete emergency contact information only if different from parent information.

Emergency Contact Full Name

Emergency Contact Email

Emergency Contact Phone

Camp Health & Emergency Forms

Physicians Name

Physicians Phone

Dentist Name

Dentist Phone

List any Prescriptions your child takes at home, (Include inhalers, Insulin, antidepressants, cardiac, behavioral medications, etc.)

*In order for your child to take medication during their stay, You must provide all medications in the original and current prescription container with a prescription label. This includes prescription medication such as inhalers, Epipens over the counter medication, including cough syrups, nasal sprays, etc.

Other health conditions not listed

If your child is diabetic, do they need finger stick testing at school?

Yes (You must provide your own glucometer)

No

Does your child have allergies?

Yes

No

List all allergies your child has.

Does your child need an EpiPen for their allergies?

Yes

No

Parent Consent Forms

Authorization and Acknowledgement:

By signing this waiver and consent, I, the legal parent/guardian grant permission for my child to participate in any and all activities during the April Youth Innovation Program at Lasell University unless otherwise specified on the Medical Form. I acknowledge that the possession or use of alcoholic beverages and illegal drugs are strictly forbidden. I understand the possession of any weapon (firearm, knife, explosives, etc.) is strictly forbidden on university property. I agree to release and hold harmless Lasell University and its senior leadership, trustees, directors, officers, employees, agents, affiliates, volunteers and medical staff (“Staff”) from any and all injury claims of any other nature which may result from my/my children’s participation at and travel to or from the university. I agree to indemnify and hold Lasell University, its Staff and other students at the university harmless from any and all liability caused by myself/my children, whether or not intentional.

Medical Consent:

The university will make every effort to contact you in case of an emergency. I give my permission for Lasell University to arrange for any necessary medical treatment to my child while at the University, including transportation to the closest offsite emergency care. I accept responsibility for the costs of all such medical treatment.

I accept

I decline medical care release for my child and/or family.

Photography Release:

In consideration of my/my children’s participation at Lasell University, and without any further consideration from the University, I hereby grant permission to utilize my child's appearance, performance or voice in any and all manner and media throughout the world for the purpose of promotion, reporting or publication. The Center may use my/my children’s name, likeness, voice and biographical material in connection with the publication, promotion, exhibition and distribution of such material. I understand that no royalty, fee or any other compensation of any kind shall become payable to me by reason of such release and use of any photography.

I accept

I decline photography release for my child and/or family.

I have read this form carefully and have had all questions answered before signing this legal document and giving the consent and waivers contained in it. I acknowledge that this is a legal document and I will be bound by my agreement to its terms. I represent to Lasell University that all information provided on this form and the Medical Form is accurate and complete and that I have the legal authority to provide consent on behalf of my child.

Typing your name below represents legal authority for the child listed above.

Date signed.

Youth Innovation Program - Application