TEACH Precollege 2016
Saturday, June 11 – Saturday, June 25
www.uwstout.edu/teachprecollege
One program. Two weeks. Three universities.
UW-Stout ● UW-Eau Claire ● UW-River Falls
PROGRAM SUMMARY
The TEACH Precollege program is a two-week summer precollege program for high school students interested in learning
more about careers in teaching. Whether the student is undecided on a career or absolutely interested in teaching, this
program offers a wide array of opportunities to explore these possibilities. Participants will spend the first week at UWStout, transition to UW-River Falls for the weekend, and complete the second week at UW-Eau Claire. Participants will live
on each campus in the dorms—all while participating in academic classes, leadership activities, and fun field trips.
REGISTRATION & CONTACT INFO
Send all application form/materials to:
Please type or print clearly in black or blue ink.
Dang Yang
TEACH Precollege Director
School of Education, UW-Stout
PO BOX 790
267 Heritage Hall
Menomonie, WI 54751-0790
Email:
Phone:
Fax at:
yangda@uwstout.edu
715-232-4047
715-232-1244
If you have any questions about this form please
contact Dang Yang, TEACH Precollege Director.
APPLICATION DEADLINE: MAY 6th, 2016
Application checklist
 Completed Registration Form
__Student Information
__Student High School & Academic Info
__Parent/Guardian Information
__Student Essay & References
__Parent/Guardian Permission Slip & Signatures
__Health & Medication Form
__Ropes Course Permission Slip
 Photocopy of family Health Insurance Card
In case of medical emergency
 Registration Fee ($15.00)
Make checks payable to: “UW-Stout”
Please do not send cash
 Copy of most recent transcript (unofficial) or attach
a list of all courses taken in high school
REGISTRATION FEE
Precollege Contacts
The TEACH Precollege 2016 program requires a $15.00 non-refundable
registration fee. Please make checks payable to: “UW-Stout”. Please do not send
cash.
Please contact us right away if you have any questions about the registration fee.
TRANSPORTATION
There are two (2) transportation options:
1.
2.
Parents may elect to drive their child to the UW-Stout Campus.
Further driving details will be sent after registration is complete.
--or-UW-Stout will provide transportation via a bus or minivan to the campus. Pick-up
locations may include the Eau Claire, Wausau, Green Bay, and Milwaukee areas
depending on enrollment. Students from Minnesota will be picked up in the St.
Paul area.
UW-Stout
Dang Yang, TEACH Director
yangda@uwstout.edu
715.232.4047
UW-Eau Claire
Sandy Moua, Co-Director
mouasand@uwec.edu
715.836.5832
UW-River Falls
Tyler Koepke, Coordinator
Tyler.koepke@uwrf.edu
715.425.3285
Make your selection on Page 4 of this registration packet.
Please note: All Parents/Guardians are responsible for arranging their own
transportation for their children from UW-Eau Claire back home after the
program. Prior arrangements must be made. We strongly encourage parents/
guardians to pick up their children on Saturday, June 25th, so they may
participate in “Family Day”—scheduled for the morning of Saturday, June 25th.
UW-Stout TEACH Precollege Registration Packet | 1
TEACH Precollege 2016 Registration Form
Please type or print clearly in black/blue ink.
Section 1. Student Information
Student First Name/Last Name (please print) :
Date of Birth: _____ /_____ /_______
mm
dd
yyyy
Gender:
□ Female □
Male
SSN (optional)*:
Mailing address where precollege materials & information should be sent:
Student Street Address:
City/State/Zip:
Student Home Phone:
Student Cell Phone:
Student Email:
□ Yes □ No
□Other:
Has the student previously applied or attended the TEACH Precollege program?
□XS □S □M □L □XL □XXL
Any religious accommodations:
□ Yes □ No Please describe:
Any dietary restrictions/accommodations: □ Yes □ No Please describe:
Student T-Shirt Size (circle one):
Student Race/Ethnicity/Nationality – Please check all that apply.
___African American or Black
___American Indian
___Asian
___Cuban
___Hispanic/Latino(a)
___Hmong
___Mexican/Chicano
___Native Hawaiian/Pacific Islander
___Puerto Rican
___White
___Other (please specify):
Section 2. Student High School & Academic Information
Current High School:
Current GPA (approximate):
Current Grade Level (15-16 year):
Highest level MATH class taken as of June 2016:
Highest level ENGLISH class taken as of June 2016:
Does your family currently qualify for or receive Free/Reduced Lunches?
Does your family currently qualify for or receive any other state or federal support (TANF, food stamps, etc.)?
□ Yes
□ Yes
□ No
□ No
Section 3. Parent/Guardian Information
Parent/Guardian Contact Information (These contacts will also be used in case of emergencies)
Parent/Guardian Name (First/Last):
Relationship to Student:
Home Phone:
Cell Phone:
Work Phone (if available, in case of emergency):
PRIMARY Head of Household
Have you earned a bachelor’s degree from a four-year
college or university?
□ Yes
□ No
SECONDARY Head of Household
Have you earned a bachelor’s degree from a four-year
college or university?
□ Yes
□ No
**Social Security Number (SSN) Disclosure and Usage: The University of Wisconsin System requests/uses SSN’s to measure the impact of
precollege program participation on college enrollment. No statute or other authority requires disclosure of SSN for that purpose. Failure to
provide SSN, however, may decrease the ability of the UW System to measure the impact of precollege program participation. Further
disclosure of SSN is restricted by the Wisconsin Public Records Act and other State and Federal Laws.
UW-Stout TEACH Precollege Registration Packet | 2
Section 4. Student’s Essay & References
Student Essay
In a few sentences or more, please describe why you want to be a teacher
(Please hand-write legibly or include a typed attachment):
Please list the contact information for two of your teachers, counselors, or school staff members who could
provide you with good references (one minimum): (Please note: We reserve the right to contact these
references, but disclosure of references does not mean we will contact all of them)
Name:
School:
Title and/or Subject Area & Grade Level (i.e. teacher, principle, school staff, etc.):
Contact Email and/or Phone:
Name:
School:
Title and/or Subject Area & Grade Level (i.e. teacher, principle, school staff, etc.):
Contact Email and/or Phone:
UW-Stout TEACH Precollege Registration Packet | 3
Section 5. Parent/Guardian Permission Slip & Signatures
Parental/Legal Guardian Consent for Child’s Participation
I, the parent/legal guardian, voluntarily indemnify and hold harmless the TEACH Precollege program, the University, the Board of
Regents of the University of Wisconsin System, their respective officers, employees, and agents from any and all liability, loss,
damages, costs, or expenses (including attorney’s fees) arising out of my child’s participation in the participation of the program
including: transportation to/from each university, off-campus activities, on campus activities, and off-campus field trips, and which do
not arise out of negligent acts or omission of an officer, employee, or agent of the University and/or Board of Regents while acting
within the scope of their employment or agency. All risks attendant to observing and/or participating in the program are hereby
assumed by the student and parent(s) and/or guardian(s). This Assumption and release are acknowledged and approved by the
signature at the end of this agreement.
The undersigned (parent/guardian/student) acknowledges that they understand that:



Risk is involved in participating in this program
The university will not provide medical coverage and the university will not provide liability coverage
Participants and their families are encouraged to have their own health/medical insurance
I hereby give permission for my son/daughter to participate in all activities and events associated with the TEACH Precollege program.
Medical & Emergency Consent
In case of medical emergency, I understand that every effort will be made to contact me. In the event that I cannot be reached, I
consent to the TEACH Precollege program staff at UW-Stout, UW-Eau Claire, and UW-River Falls to obtain whatever emergency
treatment and/or care is deemed necessary for the health and well-being of my child during his/her participation. In the case of a
medical emergency, I grant the University, its employees, agents and representatives the authority to act in any attempt to safeguard
and preserve my child’s health or safety during my child’s participation in the program including authorizing medical treatment on my
behalf and at my expense and returning my child home at my own expense for medical treatment. I consent to any anesthetic, medical,
or surgical diagnostic testing and/or treatment to be rendered to the minor under the supervision and on the advice of a licensed
physician when the need for such treatment is immediate and/or when efforts to contact me are unsuccessful.
Transportation Release
I hereby understand that UW-Stout, UW-Eau Claire, and UW-River Falls will not be providing transportation for the students to return
home, and therefore, as the parent/legal guardian, I am responsible for arranging transportation for my child when the program
concludes on Saturday, June 25th, 2016. TEACH Precollege will only be providing a bus or minivan pick-up service from select locations
at the beginning of the precollege camp on Saturday, June 11th, 2016. Parents may also elect to drive their child/student to campus
on their own.
I, the parent/legal guardian, would prefer the following transportation arrangements for my child (check one):

I will provide my own transportation to UW-Stout
(If I choose this option, I will receive driving instructions by mail after registration is complete)

I would like UW-Stout to provide transportation to the campus
(If I choose this option, I will receive info about pick-up location, time and dates after registration is complete)
I hereby certify that I understand and agree to the transportation policy and the conditions set forth.
 Yes
 No
(check one)
Photo & Video Release
I understand that the University may take photographs and/or videos of TEACH Precollege program participants and activities. I
agree that the UW-Stout shall be the owner of and may use such photographs and/or videos relating to the promotion of future
TEACH Precollege programs. I relinquish all rights that I may claim in relation to use of these photographs and/or videos.
I certify that the above information is true to the best of my knowledge.
Student Name (please print):
Student Signature
Date
My child has my permission to participate in the TEACH Precollege program sponsored by UW-Stout, UW-Eau Claire, and UW-River
Falls. I understand that the information provided will be used solely for program evaluation and program eligibility purposes and will
kept confidential. By signing below, I certify that the above information is true to the best of my knowledge and that I agree with the
policies and regulations set forth by the UW-System, UW-Stout, UW-Eau Claire, UW-River Falls, their respective Schools/Colleges of
Education, and the TEACH Precollege program. I, the parent/legal guardian, assume full legal and financial responsibility for my child’s
participation in the TEACH Precollege program.
Parent Name (please print):
Parent Signature
Date
UW-Stout TEACH Precollege Registration Packet | 4
Section 6. Health & Medication Form
University of Wisconsin–Stout
2016 Youth Event Health Form
Youth Name:
Event Name:
TEACH Precollege 2016
Dates:
June 11-25, 2016
Age on 1st day of event
Birth date
Custodial Parent/Guardian (or spouse)
Phone Numbers: Home (
)
Sex:
Male
Female
E-mail address:
Work (
)
Cell phone (
)
Home address:
Street
City
Second parent/guardian
and/or emergency contact:
State
Phone: Home
Work
Zip
(
(
)
)
Address:
Street
City
State
Zip
CONSENT FOR MEDICATION ADMINISTRATION AND MEDICAL TREATMENT
TO THE PARENT(S) OR LEGAL GUARDIAN:
If your son, daughter, or ward will be under the age of 18 while at the University of Wisconsin–Stout, it is event/camp policy to secure
your consent for medication distribution and for the use of medical devices. The medication or medical device must be
administered by designated event/camp health staff with the exception that a limited amount of medication for life-threatening
conditions may be carried by my son/daughter/ward (i.e. bee sting kit, inhaler, insulin syringe).



Prescription medication(s) has been brought to event/camp. All prescription medication must be in the
original medicine bottle (see picture at right) and labeled with the youth participant’s name, doctor’s
name, medication name, dosage, prescription number, date prescribed, and instructions. Also,
information about any prescription medications must be provided in writing to event/camp health staff
with the information requested on the second page of this form.
Over-the-counter medications have been brought to event/camp and may be administered by camp
health staff as needed. All over-the-counter medications must be labeled with the youth participant’s
name, medication name, dosage, and instruction.
No medication(s) has been brought to event/camp.
If your son, daughter, or ward will be under the age of 18 years while at the event/camp, it is our policy to secure your agreement to
all of the following statements. By signing below:
 I am giving my consent in advance for medical treatment at an appropriate medical facility in case of illness or injury.
 I am stating that I am aware of and accept the risk inherent in the program activity.
 I attest that all information on both sides of this form is correct and up-to-date, and that I will provide any and all
significant, material, or important changes to any information in this form to event/camp staff no later than check-in.
 I agree to hold harmless and indemnify the Board of Regents of the University of Wisconsin System, and the University of
Wisconsin-Stout, their officers, agents, and employees from any and all liability, loss, damages, costs, or expenses which are
sustained, incurred or required arising out of the actions of my son, daughter or ward in the course of the event/camp.
 In the event that outside medical treatment is sought while my child/ward is a camp participant, and the child/ward is
returned to camp following the medical treatment, I hereby give permission for UW-Stout to obtain medical records and
medical information from and disclose such information to any medical facility my child/ward would be taken to.
Information disclosed may be verbal or written and relate only to the injury/illness that the camp participant is currently
being treated for.
Participant Name (Please Print)
SIGNATURE OF PARENT OR LEGAL GUARDIAN
Date
(Must complete reverse side)
UW-Stout TEACH Precollege Registration Packet | 5
UW Stout
Youth Event Health Form (Continued)
Participant Name:
Parent/Guardian Signature:
Health Conditions (check)
Allergies (check & list specifics)












Asthma Insect stings
Diabetes Foods
Epilepsy Medications
Psychiatric Other
Insect Stings
Foods
Medications
Other
Cognitive/Developmental
Any dizziness, light-headedness or fainting
associated with exercise within the past year
Any unexplained, rapid or irregular heart beat within
the past year
Do any allergies require an EPIPEN Injection?
Is an inhaler required and carried by youth?
A physician has sometime denied or restricted
participation in sports due to a heart problem
Date of last Tetanus booster:
*You may also attach an updated Immunization Record
Name of Insurance Co.:
Yes
Yes
No
No
Policy #:
Description of any limitation or restriction of event activities:
Any special accommodations regarding physical or emotional conditions that we need to be aware of regarding your child’s
participation in this event/camp (include circumstances when physician should be notified)?
Medications camper will be taking at camp:
Name of Medication
Reason
Dosage (mg)
Times of day
given
Yes
Prescribing Physician &
Phone Number
1.
Does the youth experience any side effects from the medication?
(i.e., mood/behavior changes, upset stomach, diarrhea)
No
2.
List any special instructions or additional information regarding the medication that would be helpful to the Health Care staff:
*** FOR EVENT/CAMP USE ONLY – TO BE COMPLETED BY HEALTH CARE STAFF AT CHECK-IN ***
1.
Are there any changes in your child’s health status since the medical forms were sent in?
No
Yes
2.
Has your child, or anyone in your family been sick or exposed to any communicable disease in the past month?
No
Yes
3.
Does your child now have any rashes or open sores?
No
Yes
4.
Are there any changes in your dependent’s medications? (If Yes, Staff make changes & sign)
No
Yes
5.
Does your child have any recent injury or activity restrictions?
No
Yes
6.
Will the custodial parent(s) or guardian be available at the numbers listed on this form during the camping session?
No
Yes
If NO, list the name & phone number of person(s) authorized to make decisions on their behalf if different than the emergency contact listed on the
reverse side of this form:
Information provided by:
To:
Date:
UW-Stout TEACH Precollege Registration Packet | 6
Section 7. Ropes Course Permission Slip
University of Wisconsin–Stout
University Recreation-Stout Adventures
Climbing & Challenge Course Agreement, Acknowledgment of Risk and Release
I,
Adventures.
(print name), age
, desire to participate voluntarily in recreational activities sponsored by Stout
I UNDERSTAND THAT I AM BEING ASKED TO READ THE FOLLOWING DOCUMENT CAREFULLY. I UNDERSTAND THAT IF I WISH TO DISCUSS ANY OF THE
TERMS CONTAINED IN THIS AGREEMENT, I MAY CONTACT UW-STOUT SAFETY & RISK MANAGEMENT SERVICES, AT 715-232-2258 OR 715-232-1793.
In consideration of the services of the University of Wisconsin-Stout, Stout Adventures program, their agents, owners, officers, volunteers, participants, employees,
sponsors, and other persons or entities acting in any capacity on their behalf (hereinafter collectively referred to as "UWSA”) I hereby agree to release and
discharge UWSA, on behalf of myself, my children, my parents, my heirs, assigns, personal representative and estate as follows:
Assumption of Risks
I understand there are inherent, know and unanticipated risks that cannot be eliminated from the sport of rock climbing and challenge course activities without
jeopardizing the essential qualities of the activity. I have full knowledge of the nature and extent of these risks including but not limited to:
1.
Injuries resulting from falling and crashing into the climbing wall, climbing tower, floor/ground, crash pads, giant swing, low course elements or other
obstacles.
2.
Injuries resulting from rope abrasion, entanglement, loose and/or damaged artificial holds and other injuries that may result from activities or other
persons, including but not limited to climbing, lead climbing, rappelling, belaying, lowering on a rope, rescue or emergency activities, as well as injuries,
abrasions, and cuts resulting from contact with equipment and components of the challenge course and indoor climbing wall facilities.
3.
Failure of the ropes, harnesses, wall hardware, anchor points, or any other part of the climbing structure and related equipment.
4.
Injuries from falling participants or equipment.
5.
Injuries resulting from the negligence of other course participants, belayers, spotters, spectators or users of the facilities.
6.
Injuries resulting from personal physical and mental limits including but not limited to fatigue, chill and or dizziness, which may diminish reaction time
and increase risks of accident, personal strength, coordination, sense of balance, and the ability to follow or give directions while on the course,
climbing, belaying, lifting, spotting, or being a spectator.
UWSA employees have difficult jobs to perform. They seek safety, but are not infallible. They might be ignorant of a participant’s fitness or abilities. Belayers may
give inadequate warnings or instructions, and the equipment being used might malfunction.
I KNOW, UNDERSTAND, AND APPRECIATE THE RISKS THAT ARE INHERENT IN UWSA PROGRAMMING. I HEREBY ASSERT THAT MY ARTICIPATION
IS VOLUNTARY AND THAT I KNOWLEDGABLY ASSUME ALL SUCH RISKS.
Hold Harmless Indemnify & Release
I expressly agree and promise to accept and assume all of the risks existing in the participation of recreational or sport activities within the Sports & Fitness Center
building & grounds, Indoor Climbing Wall, Challenge Course and all other facilities and locations.
I certify that I am fully capable of participating in this activity. I certify that I have no known medical or physical conditions which could interfere with my safety while
participating in recreational or sport activity, or else I am willing to assume - and bear the costs of - all risks that may be created, directly or indirectly, by any such
condition.
I accept the risk and responsibility for the condition and proper use of any personally owned safety equipment. I fully understand that no inspections or
representations are made as to the adequacy of personal equipment by anyone other than participants themselves and assume the risk that this entails.
In consideration of permission for me to voluntarily participate in Stout Adventures activity today and on all future dates, I, for myself, my heirs, my children, my
parents, assigns, personal representative and estate agree to defend, hold harmless, indemnify and release the Board of Regents of the University of Wisconsin
System, the University of Wisconsin-Stout, and their officers,, employees, agents and volunteers, from and against all claims, demands, expense (including costs
and attorney’s fees), actions or causes of action of any sort on account of damage to personal property, or personal injury, or death which may result from my
participation in Stout Adventures’ programs. This release includes claims based on negligence of the Board of Regents of the University of Wisconsin System, the
University of Wisconsin-Stout, and their officers,, employees, agents and volunteers, but expressly does not include claims based on their intentional misconduct
or gross negligence. I UNDERSTAND THAT BY AGREEING TO THE ABOVE STATEMENTS I AM RELEASING CLAIMS AND GIVING UP SUBSTANTIAL
RIGHTS INCLUDING THE RIGHT TO SUE.
Consent for Emergency Treatment
I authorize UWSA and its designated representatives the authority to act in any attempt to safeguard and preserve my health and safety during my participation. I
consent, on my behalf, to any emergency medical/hospital care or treatment to be rendered upon the advice of any licensed physician. I AGREE TO BE
RESPONSIBLE FOR ALL NECESSARY CHARGES INCURRED BY HOSPITALIZATION OR TREATMENT RENDERED PURSUANT TO THIS
AUTHORIZATION. I DO NOT PRESUME THAT ANY INSURANCE, WHETHER FOR ACCIDENT, LIFE, MEDICAL, OR PROPERTY LOSS HAS BEEN
SECURED FOR MY BENEFIT. I UNDERSTAND THAT UWSA HAS ADVISED ME TO SEEK THE ADVICE OF MY PHYSICIAN BEFORE PARTICIPATING IN
THIS ACTIVITY.
By signing this document, I acknowledge that if anyone is hurt or property is damaged during my participation in sport or recreational activity, I may be
found by a court of law to have waived my right to maintain a lawsuit against UWSA on the basis of any claim from which I have released them herein. I
have had sufficient opportunity to read this entire document. I have read and understood it, and I agree to be bound by its terms.
Signature of Participant:
Date:
Check one: ___ 18 years of age or older ___ Under 18 years of age (Parent/Guardian consent required)
Print Name: |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
PARENTS OR GUARDIAN'S ADDITIONAL INDEMNIFICATION (Must be completed for participants under the age of 18) In consideration of
__________________________________________________ (print minor's name)("Minor") being permitted by UWSA to participate in its activities and to use its
equipment and facilities, I agree to indemnify and hold harmless UWSA from any and all claims which are brought by, or on behalf of Minor, and which are in any
way connected with such use or participation by Minor.
Signature of Parent or Guardian:
Date:
Print Name: |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
UW-Stout TEACH Precollege Registration Packet | 7
University of Wisconsin–Stout
University Recreation-Stout Adventures
Medical Questionnaire
Organization/Event Name:
TEACH Precollege 2016
PLEASE READ: This form is intended to remind participants of the seriousness of attempting adventure activities with an old, pre-existing injury, heart
problem or other conditions which may be aggravated by the event.
Questions
1. Any pre-existing injuries (ankles, knees, back) that may be aggravated by the event?
Response
Yes
No
2. Are you currently taking any prescription or non-prescription medication?
If yes, what are they and what are they for?
Yes
No
3. Do you have any heart conditions?
Yes
No
4. Any pressure or coercion from employer or others to participate?
Yes
No
5. Do you have high blood pressure?
Yes
No
6. Do you have any allergies (food, bees, insects, or medicines)?
If Yes, please explain:
Yes
No
7. Do you foresee any problems participating in the upcoming Adventure Challenge Course activity
due to a lack of physical exercise?
Yes
No
8. Do you have Asthma?
Yes
No
9. Do you have a disability?
If yes, please indicate the functional implications and any concerns about participation related to the disability.
Yes
No
If Yes, please explain:
Emergency Contact
In case of emergency, contact:
Relation:
Phone:
Note to Staff: If “Yes” is circled, please discuss with the participant. If, in your judgment according to your training, a participant should not engage in
the activities due to health or safety risks, then ask them to observe only.
Participant – Please read and sign
I have honestly disclosed to the staff any medical, psychological or personal reasons that might affect my safety or the safety of others during these
events. I will remember that a “Challenge by Choice” atmosphere exists at all times and I should not feel pressured to participate. I agree to stop
participating immediately if I experience any pain, faintness, dizziness, or shortness of breath. In addition, I grant permission to use my Image in print or
online materials designed for news, informational or educational purposes related to the University of Wisconsin-Stout.
Signature of Participant:
Date:
Print Name: |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
If Applicable (Must be completed for participants under the age of 18):
Signature of Parent or Guardian:
Date:
Print Name: |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
UW-Stout TEACH Precollege Registration Packet | 8