Registration Application June 6-10, 2016 PARTICIPANTS MUST SHOW PROOF OF MEDICAL INSURANCE TO PARTICIPATE TO BE COMPLETED BY PARENT OR LEGAL GUARDIAN. Please print in ink or type, and be careful not to skip any sections of this form, as all sections are required for registration. Prepayment, in full, is required to reserve your space. Return the completed application to info@cci-atl.org no later than Friday, May 27, 2016 STUDENT INFORMATION Male Female Last name First name Middle initial Birth date (month/day/year) Age Home Mailing Address (No. and Street, or PO Box No.) City State ZIP Code Country Home Phone No. Special dietary needs/accommodations (if none, leave blank): Page 1 of 8
Registration Form - Continued PARENT/LEGAL GUARDIAN INFORMATION Parent s/legal Guardian s last name First name Email address of Parent/Legal Guardian The Atlanta Center for Creative Inquiry Summer Academy will use this email address to communicate logistical information regarding the Summer Academy. Daytime phone no. Home phone no. Cell phone no. Academy Participant Pickup: Name of person who will be picking up the student. Name Phone no. Relationship to participant This Summer Academy is available to high school students only (entering 9th grader through justgraduated senior). Student s grade next fall (check one): Entering 9th grade in fall Entering 10th grade in fall Entering 11th grade in fall Entering 12th grade in fall 2015 high school graduate Each camp participant will have exposure to both architecture and landscape architecture. Please express the area of greatest interest to the participant: Architecture Engineering T-shirt size (T-shirt provided at on-site registration at no additional cost.): S M L XL XXL (If no size is indicated, the participant will receive a large T-shirt.) Release I/We, the undersigned, individually and as parent(s) or legal guardian(s) of, a minor, ask that he/she be admitted to participate in this Summer Academy sponsored by The Atlanta Center for Creative Inquiry. In consideration of such admission, I/we do hereby agree to release, discharge, and hold harmless The Atlanta Center for Creative Inquiry, its Officers, Agents, and employees of and from all causes, liabilities, damages, claims, Page 2 of 8
or demands whatsoever on account of any injury or accident involving the said minor arising out of the minor s attendance at the camp or residence in the course of activities held in connection with the camp. Additionally, I authorize The Atlanta Center for Creative Inquiry Summer Academy to photograph, videotape, and/or audiotape my child in promotion of the Atlanta Center for Creative Inquiry Summer Academy. I/We have reviewed the Standards of Conduct (attached) with my child, who agrees to follow this code. Signature (At least one is required to complete registration.) Registration Form - Continued Parent s/legal Guardian s signature Date Field Trip Permission I/We give permission for my/our child to participate in the following field trips: construction site visits located on the Georgia Institute of Technology campus and/or local vicinities. Note: Participants are to wear long pants, hard-soled closed-toe shoes (no sneakers or sandals, for example) and shirts with 4- inch sleeves, minimum length, when visiting a construction site. Yes No Signature (At least one is required to complete registration.) Parent s/legal Guardian s signature Date Registration Fee $75 fee per participant (on or before April 15, 2016) $100 fee per participant (from April 16 through May 22, 2016) $150 fee per participant (after May 27, 2016) Method of Payment To make your payment go to https://www.eventbrite.com/e/acci-summer-academy-2016- tickets-24469662419 using Visa, MasterCard, Discover or American Express. Health Form and other other Information The next two pages contain the Health Form and must be completed and returned with the registration form. Also attached is the Academy s Standards of Conduct and Frequently Asked Questions (FAQ). Page 3 of 8
Health Form This form must be completed and returned before youth camp/program/event enrollment dates in order for youth to be permitted to participate in any program activities. Personal Information Participant s Last Name First Name Birthdate M F Specify program your child will be attending Address City State Zip Home Phone E-mail Address Parent/Guardian #1 Parent/Guardian #2 Daytime Phone Daytime Phone Place of employment Place of employment Health Insurance Carrier Policy Number Plan Number Is physician authorization needed? Yes No Name of Family Physician Phone In case of emergency, please notify If neither parent nor guardian is available in an emergency, please contact: 1. Phone 2. Phone Health History [Please check and provide approximate dates that youth suffered from allergies and other conditions listed below] Allergies Hay Fever Bee/Wasp Stings Insect Stings Penicillin Peanut Other Food/Drugs: Other Asthma Diabetes Convulsions Concussion Behavioral/Emotional Other: Date of most recent tetanus immunization: Please list any major past illnesses (contagious and non-contagious): Please list any major operations or serious injuries (include dates): Has the youth ever been hospitalized? Does the youth have any chronic or recurring illness? Is there anything else in the Participant s health history that the Academy s staff should know? Are there any activities from which the Participant should be restricted? Are there any specific activities that should be encouraged? Does the Participant have any special dietary restrictions? NO Yes If YES, explain: Does the Participant wear any medical appliances (glasses, contact lenses, orthodonture, etc.)? NO Yes If YES, explain: Will the Participant need to take any medication during the program? NO Yes If YES, please list the specific prescription or over-the-counter medications below, reasons for medication, and daily dosage. If any medications change prior to arriving at the program, please provide an updated list upon arrival. Medication Reason(s) for Medication Daily Dosage/Time(s) Taken 1 2 3 4 If at all possible, medication should be administered at home. Medications will be allowed at the Academy only when failure to take such medicine would jeopardize the health of a child and he/she would not be able to attend the Academy if the medicine were not made available. Page 4 of 8
Health Form Page 2 Participant s Last Name First Name Birthdate M F The parent(s)/legal guardian(s) of participants are required to disclose their intention to bring medications to the Academy, especially to treat potentially life-threatening conditions (i.e. inhalers, EPI-pens, insulin injections). Upon arrival to the Academy, parent(s)/legal guardian(s) should plan to meet with a member of Academy staff at registration to review medication issues for the participant and complete additional required paperwork if not completed prior to arrival. All medications (prescription and over-the-counter) must be stored in the original product packaging and clearly labeled with the participant s name. Prescription medication(s) must also include a label with the medication s name and dosage instructions, as well as the prescribing physician s name and telephone number. All medications will be kept in a secure location and those that require refrigeration will be stored appropriately. Access to all medications will be limited to approved personnel. Academy staff will NOT purchase medications of any type (prescription or over-the-counter) for participants. With advance notice/permission, participants may carry emergency medication (i.e. inhalers, EPI-pens, insulin injections) on his/her person. Academy staff will not dispense medications, but may monitor the self-administration of certain medications if necessary, ONLY upon written consent of the parent(s)/legal guardian(s) and /or physician s orders. It is NOT permissible for a participant to share any medications with any other participants. It is the responsibility of the parent(s)/legal guardian(s) to be sure that the participant s medications brought to the Academy are not left behind at the end of the program. Failure to do so will result in the medications being destroyed within three working days after the participant s last day at the program. Absolutely no medications will be returned via mail regardless of circumstances. HIPAA The Atlanta Center for Creative Inquiry honors the privacy of the participants in its Programs and complies with the national regulations regarding health information. Parent/ Legal Guardian Name (please print) Date: Parent/ Legal Guardian Signature * Terms and Conditions agreed to via electronic signature Page 5 of 8
Standards of Conduct The following policies and guidelines have been developed to help you gain the maximum benefit from your summer experience at The Atlanta Center for Creative Inquiry Summer Academy. If you have questions about them, please talk to one of the program counselors. Failure to observe these standards may result in expulsion from the Academy. Any student dismissed from the Academy for disciplinary reasons will not receive a refund. General Policies If you are ill, see one of the program staff or counselors immediately. Participants are to report on time to all scheduled activities. Participants are required to participate in all scheduled activities. Only an Academy staff member may grant permission to be excused. Courteous and respectful behavior is expected at all times to all Academy staff and participants. Participants are not permitted to leave the activity areas or go off the Academy campus unless accompanied or granted special permission by an Academy staff member. Misuse or damage of Academy or university property is unacceptable. Charges will be assessed against participants responsible for damage or missing Academy or university property. Cell phones and other electronic devices, including earbuds, may not be used/on during class or special sessions. You must abide by the following regulations which prohibit the following: Parking Possession and use of alcohol or other drugs Possession of fireworks, guns, and other weapons Stealing Violence of any kind (This includes sexual harassment.) Tobacco products (Smoking is prohibited in all university buildings.) If you drive a car to a summer the Academy, you must pay for parking and park in your assigned parking lot. Failure to do so may result in a parking fine. Dismissal Please keep in mind that during their classes at the university students are representing themselves, family, school, and community. While unacceptable conduct is not anticipated from participants, the Academy is prepared to deal with situations involving inappropriate behavior. The Atlanta Center for Creative Inquiry maintains the right to dismiss any student for improper conduct. Any student dismissed from the Academy will not receive a refund. A parent/guardian will be notified immediately and expected to pick up the participant. Page 6 of 8
Frequently Asked Questions QUICK REFERENCE EMERGENCY PHONE NUMBERS EMERGENCY CITY OF ATLANTA POLICE / FIRE / AMBULANCE. 911 Georgia Tech Police 24 Hour Emergency Contact.404-894-2500 Registered academy students and their parents will be given the Academy Director and staff s work cell phone numbers during registration. When does the camp begin and when should I register? The Academy is a one-week program that starts on June 1 st and ends on June 5 th. Registration is now open and is on a firstcome, first-serve basis. Space is limited so return your application and make your payment today. How do I register for the Academy? Download a copy of the application at www.cci-atl.org Complete the form and return to info@cci-atl.org Pay your registration fees at https://www.eventbrite.com/e/acci-summer-academy-2016-tickets-24469662419 using Visa, MasterCard, Discover or American Express Cost: Before April 15 th - $75; April 16 th - May 22 nd - $100; and after May 22 nd - $150. What happens after I register? Once you register and pay for the Academy, you will be sent a confirmation email to the address you entered with your registration. Additional Academy information will come to that same email address as the Academy dates get closer. What does the cost of Academy include? Academy costs cover tuition, meals, healthy snacks and drinks, a t-shirt, and all Academy-specific project materials and supplies. What insurance information do I need to provide? Each student is required to have proof of medical insurance on file. This information is requested on the registration form. Can my child drive his/her personal vehicle to the Academy? Yes, students are allowed to drive to the Academy, but there is no free parking on campus. Students must park in a designated parking lot and pay the lot attendant. When is Academy check-in? Students are expected to be at the Hinman Building and in his/her designated seat BEFORE 9am each morning. Where is Academy check-in? The College of Architecture Building is located at 247 4 th Street NW, Atlanta, GA 30332. The Hinman building is across the street and up the hill. When is Academy check-out? Academy check-out is 5pm but staff will be in the building until 5:30pm to accommodate late pick-ups. What clothing should my child wear? The temperature during the summer months is usually hot and humid. We urge students to bring cool cotton clothes. Shorts and comfortable shirts are acceptable attire. We expect students to dress as they would in their own school. During the day, we will move around the campus; comfortable walking shoes are must! Do not forget to include an umbrella or raincoat!! Also, on the last day (Friday) please wear a nice outfit (dress or shirt with nice pants, etc.) because we will have a final jury with outside jurors in attendance! Does my child need to bring any spending money to Academy? All program expenses (except transportation to and from the Academy) are covered by the Academy fee, so there is no need for any student to bring large amounts of money to the Academy. Students may want to bring some cash, however, to purchase optional items such as snacks and/or souvenirs. Page 7 of 8
Frequently Asked Questions - Continued Will my child have access to internet? Depending on Academy academic programming, students may have limited internet access. Students will not have internet access during the classes. Who supervises my child at Academy? Academy participants are supervised by a team of professional instructors and assistant instructors. There will be male and female counselors that reflect the Academy s demographic composition. Members of our nationally recognized-faculty will lead academic programming and are joined in the classroom by our Academy counselors. How do you select your counselors? Academy counselors are Kennesaw State undergraduate ar c h i te c t ur e students who were vetted through an extensive hiring process to include a series of interviews and a criminal background check. Where will my child eat at the Academy? Academy participants will eat their lunches in the College of Architecture at Georgia Tech. What if my child has a food allergy? The Academy cannot provide special meals for participants with food allergies. Should your child have food allergies, you are welcome to send any special food accommodations that may be necessary. Where can I find an Academy schedule? Final schedules will be provided during registration/check-in. What if a student needs to leave during the Academy? Academy participants are to remain with the group on campus for the duration of the program unless program activities require otherwise. If a student must leave the campus for some reason, we must receive prior written permission from the parent/guardian. Permission must be granted by the Academy Director in advance. What is the Academy cell phone policy? Cell phones offer the best means for students and parents to keep in touch during Academy; therefore we do not prohibit cell phone use before and after classes at the Academy. However, cell phones should not be used during academic programming and should never be a source of disruption in the classroom. Parents should set clear guidelines and limitations for cell phone use during Academy. Participants will refrain from using electronic devices (i.e. cell phones, ipads, computers, etc.) during instructional periods unless otherwise authorized. If students are unable to adhere to this policy, the Academy Director may confiscate the device until the end of Academy. TRAVELLING TO/FROM THE GEORGIA INSTITUTE OF TECHNOLOGY How do I get to Georgia Tech s campus from Atlanta? Transportation to and from your home will be the responsibility of the student and his/her family. The Georgia Tech campus is easily accessible by car from I-75/85. A map of the Georgia Institute of Technology campus is available online: http://map.gtalumni.org/ The Academy will be located in the College of Architecture's Hinman Building on 4 th Street. Students may be dropped off in front of the College of Architecture's Hinman building between 8-8:30am and picked up at the end of the day between 5pm and 5:30pm. EVALUATIONS How do we provide Academy feedback? We are constantly working to improve our Academy and request constructive feedback from students and parents alike. Students will complete an evaluation form prior to Academy graduation. Parents are also encouraged to provide feedback. If you have any additional questions, contact the ACCI Academy at info@cci-atl.org. Page 8 of 8