Blugold Beginnings Summer Camps
2016 Application
Note: All Camps are Free to ECASD Students
Please send completed application to:
University of Wisconsin-Eau Claire
Attn: Blugold Beginnings, Centennial Hall 1106
105 Garfield Ave
Eau Claire, WI 54702-4004
Please rank the camps below in order of preference (i.e. 1-8):
Science, Technology, Engineering, Math (STEM) Camps (6th-12th grade)
___ Session 1: Overnight in UW-Eau Claire Residence Hall: June 12th-17th, $275 per student
___ Session 2: Day Camp: July 18th-22nd (8:00 am -5:00 pm), $175 per student
Exploring the Arts (6th-12th grade)
___ Session 1: Day Camp: June 20th-24th (8:00 am -5:00 pm), $150 per student
___ Session 2: Overnight in UW-Eau Claire Residence Hall: June 26th-30th, $250 per student
Dreaming Big, Planning Big – Entrepreneurship Camp (6th - 12th grade)
____ Session 1: Overnight in UW-Eau Claire Residence Hall: July 10th-July 15th, $275 per student
Bio-Medical and Kinesiology Camp (6th-12th grade)
____ Session 1: Overnight in UW-Eau Claire Residence Hall: July 31st-August 5th, $275 per student
Service and Leadership Camp (9th-12th grade)
____ Session 1: Day Camp: July 25th-29th (8:00 am -5:00 pm), $100 per student
Splashing into Middle School Camp (students entering 6th grade)
____ Session 1: Day Camp: August 8th-12th (8:00 am -5:00 pm), $100 per student
Navigating Ninth Grade Camp (students entering 9th grade)
____ Session 1: Day Camp: August 8th-12th (8:00 am -5:00 pm), $100 per student
Letters will be sent upon receipt of your application to confirm your camp selection.
2016 UW-EAU CLAIRE Blugold Beginnings Precollege Summer Camp Registration
Student Name: l a s t
_______________
Date of Birth: __ M M / D D / Y Y Y Y
Current School Grade Level:
first
___
___________
middle
Gender:  Male  Female
School Attending: _______________ District Attending: _______________________
Race/Ethnicity –Check ALL that apply.
a. What is the student’s race? Please check ALL that apply.
 American Indian/Alaska Native – please specify principal WI or Other tribe & reservation
 Asian Indian
Spanish/Hispanic/Latino
 Guamanian or
Chamorro
 Black or African American
 Cambodian
 Hmong
 Japanese
 Chinese
 Korean
 Filipino
 Laotian
 Native Hawaiian
 White
 Samoan
 Vietnamese
 Other Asian – please specify
 Other race – please specify
Student Primary Contact Information (primary phone number and address)
Name:
Relationship to Student:
Street Address:
City/State/Zip:
Home Phone Number:
Cell Phone:
Work Phone Number:
Student/Contact e-mail:
HEAD OF HOUSEHOLD 1
Have you earned a bachelors degree from a four-year
college or university? ___No ___Yes
HEAD OF HOUSEHOLD 2
Have you earned a bachelors degree from a four-year
college or university? ___No ___Yes
Does your family qualify for or receive Free or Reduced lunches?
Is the student a Gear Up participant?  Yes
 Yes
 No
 No
I certify that the above information is true and correct to the best of my knowledge.
Student Signature
Date
has my permission to participate in the Precollege Programs sponsored by the
University of Wisconsin-Eau Claire and the Wisconsin Department of Public Instruction. I understand that the
information provided will be used solely for program evaluation and program eligibility purposes and will be kept
confidential.
Parent Signature
Date
BLUGOLD BEGINNINGS HEALTH HISTORY QUESTIONNAIRE
_________________________________________________________________________________________________________________
Name: Last
First
MI
_____________________________________________________________________________________
ADDRESS: Street
City
State
Zip
Parent/Guardian:_______________________________________Relationship:_____________________
Home Phone: (_______) ________-___________ Work Phone: (_______) _________-_____________
Address (if different from above):__________________________________________________________
Cell Phone: (______) __________ - _______________
In case of emergency (injury or illness), if you are unable to be contacted:
Name: ________________________ Relationship:__________________ Phone: ___________________
Name of person on insurance card: ____________________________________________
Name of Physician: ____________________________________ Phone:_______________
Name of Insurance Co: ____________________________Policy # ____________________
Date of Birth
/
/
Sex
F M
Does participant have allergic reactions to:
YES
□
□
□
□
NO
□
□
□
□
Penicillin____________________________
Other Antibiotics______________________
Other Medicines (type)_________________
Insect Bites/Stings_____________________
Height
Weight
Immunization Record:
*MMR (measles, mumps, rubella)
Dose 1 – Immunization at 12 months
Dose 2
*Tetanus-Diphtheria
Year of initial series
Year of last tetanus booster
_____/____/_____
_____/____/_____
_____/____/_____
_____/____/_____
Have you ever had major surgery or been hospitalized?  YES  NO
Please explain any significant operations, accidents or illnesses, and last medical attention and reason:
__________________________________________________________________________________
__________________________________________________________________________________
Does the participant have any physical condition(s) requiring special considerations?  YES  NO
Explain:____________________________________________________________________________
__________________________________________________________________________________
Is participant taking any medication regularly?  YES  NO
If yes, identify
Has participant had or presently experiencing:
YES NO
YES NO

 Allergies
  High Blood Pressure

 Asthma
  Joint Injury/Surgery

 Bleeding Disorder
  Kidney Disease

 Cancer
  Menstrual Difficulties

 Colitis
  Mental/Emotional Prob.

 Diabetes
  Neck/Back Pain/Injury

 Epilepsy/Seizures
  Rheumatic Fever

 Heart Disease
  Tuberculosis

 Hernia
  Ulcer
Other: _________________________________________________________________________________________
EMERGENCY CONSENT: In case of medical emergency, I/we understand that every effort will be made to
contact me. If I/we can’t be reached, I/we authorize the Blugold Beginnings staff at UW-Eau Claire to obtain
whatever emergency treatment and/or care necessary for the health and well-being of the student
__________________________________
Signature of parent/guardian
_________________________________
Relationship
___________
Date
PARENTAL CONSENT and PHOTOGRAPH RELEASE
2016 PRECOLLEGE PROGRAM(S)
I agree that the University of Wisconsin-Eau Claire and/or the UW-Eau Claire staff and/or employees shall not be held
responsible for any personal injury, loss of, or damage to, property, however caused, and agree to release UW-Eau Claire,
UW-Eau Claire staff and/or employees from all claims of damages which may arise as a result of any such personal injury
or loss suffered during the course of the students participation in the Precollege Programs. All risks attendant to observing
and/or participation in the Precollege Programs are assumed by the student and parent(s) and/or guardian(s). This
assumption and release are acknowledged by the signatures below.
The University of Wisconsin-Eau Claire and/or the Blugold Beginnings staff reserves the right to terminate the stay of any
student, without refund and without formal hearing, when it is deemed by the University and program staff and employees.
The University and the Blugold Beginnings staff reserve the right to establish and determine the standards of conduct of
participants engaged in the program and to require compliance with these standards as a condition of continued
participation.
Signature of parent/guardian
Relationship
Date
PHOTOGRAPH RELEASE
I understand that the University may take photographs of Precollege Program participants and activities. I agree that the
University of Wisconsin-Eau Claire shall be the owner of and may use such photographs relating to the promotion of future
Precollege Programs. I relinquish all rights that I may claim in relation to use of these photographs.
Signature of parent/guardian
Relationship
Date
2016 CODE OF CONDUCT AGREEMENT
Safety is our number one concern!
In order to maintain a safe, productive, and fun learning environment, all students need to follow these
guidelines. There will be consequences for any violations of these expectations:




Students are responsible for attending all scheduled events on time.
Students are required to stay in the designated activity area for all structured activities including the
evening activities. If you need to leave an activity, you need to get permission from the Blugold
Beginnings’ staff. For safety reasons we need to know where you are at all times.
No student is allowed to leave the UW-Eau Claire campus unless given permission in advance from the
Blugold Beginnings’ staff, who will confirm with your parents(s) or legal guardian(s) that you need to
leave.
The use of alcohol and drugs, including tobacco is strictly prohibited.
Overnight Camp Only:
 Remain in your assigned residence hall room after 10 p.m. until 7 a.m., unless there is an emergency
(i.e., illness, fire drill, etc.)
 Outside visitors are NOT allowed at the residence hall, any unexpected visitors will be asked to leave
immediately.
I agree with and will abide by, the code of conduct agreement during my attendance.
I understand that my participation is a privilege and I will respect others and myself. I understand that if the
Blugold Beginnings finds my behavior inappropriate they will call my parents(s) or legal guardian(s) for
immediate pick-up at their expense.
Signature of participant
Signature of parent or guardian
Date
Date
YOU MUST RETURN THIS SIGNED AGREEMENT WITH YOUR COMPLETED APPLICATION MATERIALS.
INSTRUCTIONS TO THE STUDENT AND PARENT/GUARDIAN:
Student must be eligible for Free or Reduced Price School Meals and, must have
finished Fifth Grade, but not have graduated from High School to receive a DPI
Precollege Scholarship. Fill out Section I completely. Parent/Guardian must sign
in the space provided. Give this form to your Principal, Food Services Authorized
Representative or a DPI/WEOP Staff Member for completion of Section II.
Students who are disruptive or sent home from a Precollege Program may forfeit
the opportunity to participate in future programs.
Wisconsin Department of Public
Instruction
PRECOLLEGE SCHOLARSHIP
APPLICATION
PI-1573 (Rev. 04-12)
Please submit this completed form with your Blugold Beginnings
application, please mail to the following address:
University of Wisconsin-Eau Claire, Attn: Blugold Beginnings
105 Garfield Avenue, Eau Claire, WI 54702
You may receive a maximum of three DPI Precollege
Scholarships per year.
I. STUDENT INFORMATION
Name Last
First
Middle Initial
Street Address
City
Date of Birth
State
Zip
Sex
Male
Female
Check only one (For Statistical Purposes)
Hispanic or Latino
Not Hispanic or Latino
Check all that apply
American Indian or Alaska Native
Asian
Black or African-American
Native Hawaiian/Other Pacific Islander
Current Grade Level
5
White
Anticipated Year of High School Graduation
6
7
8
9
10
11
School Presently Attending
12
School District Name
I HEREBY AUTHORIZE release of my child’s verification of Free or Reduced Price School Meals eligibility to the Precollege Campus and DPI.
Date Signed Mo./Day/Yr.
Signature of Parent/Guardian

II. VERIFICATION AND RECOMMENDATION
Instructions to the Principal, Food Services Authorized Representative, or DPI/WEOP Staff Member:
Please verify that this student is eligible for Free or Reduced Price School Meals and forward this application form to the College or University where
the student has applied for admission to a DPI Precollege Program.
Is this student eligible for Free or Reduced Price School Meals?
Yes
No
I have verified that this student is eligible for Free or Reduced Price School Meals and I recommend this student for a DPI Precollege
Scholarship.
Name of Authorized Representative
Verification Signature

Title
Telephone Area/No.
Date Signed Mo./Day/Yr.