GEAR UP NC Summer Residential Enrichment Program
UNC Charlotte STEM/Biotechnology Program
July 7-11, 2014
GEAR UP Student Name: ___________________________________________
GEAR UP School District: ___________________________________________
Grade Level (during 2014-15): _______________________________________
Please circle one:
Participant
Alternate
Please complete and return all sections of this packet to your
GEAR UP Coordinator/Facilitator
_____ GEAR UP NC Short Essay: Student participants and alternates are to respond to the
following short essay question in 250-500 words typed, printed, and stapled to this forms
packet. Be sure to proofread your essay!
Why would you like to attend this program and what do you hope to gain from this program
to prepare you for postsecondary education?
_____ UNC General Administration GEAR UP NC Student Release Forms
_____ UNC Charlotte Student Release Forms
Note: GEAR UP Coordinators/Facilitators must send all original completed participant and
alternate forms and the GEAR UP NC Short Essay via FedEx by March 17, 2014 to:
GEAR UP NC
140 Friday Center Drive, Room 240
Chapel Hill, NC 27517
UNCC - Summer 2014
1
SHORT ESSAY
UNCC - Summer 2014
2
2014 Summer Residential Enrichment Programs
STUDENT RELEASE FORM
TO BE COMPLETED BY STUDENT AND PARENT/GUARDIAN
Student Information
Name of Student:
School Name:________________________________________________________
______
Email Address: __________________________________________________________________
Current Home Address:
City:
Zip:
Emergency Contact Information (At Least 1 Required)
Name of Parent/Guardian #1: ____________________________________________________
Home Phone: ______________________
Cell Phone: ________________________
Work Phone: ________________________
Other: ______________________________
Name of Parent/Guardian #2:
____________________________________________________
Home Phone: ______________________
Cell Phone: ________________________
Work Phone: ________________________
Other: ______________________________
To Be Completed by Parent /Guardian
Please provide the name and phone number of a close family friend or nearby relative that we may
contact in the event of an emergency if parent(s)/guardian(s) are unavailable (At least 1 required):
Emergency Contact #1: ____________________________________________________
Phone Number(s):
__________
Emergency Contact 2: ____________________________________________________
Phone Number(s):
UNCC - Summer 2014
__________
3
2014 Summer Residential Enrichment Programs
STUDENT RELEASE FORM
TO BE COMPLETED BY STUDENT AND PARENT/GUARDIAN
Insurance Information
My child is currently covered under the following (check one):
Parent/Guardian Insurance (See section 1)
Medicaid/Medicare (See Section 2)
Information Not Available (Skip to page 5)
Section 1: Guardian/Parent Insurance:
Insurance Company Name and address:
Policy Holder’s (P.H.) Name:
Address:
Relation to Student:
City, State, Zip:
Occupation:
P.H.’s Employer’s Name and address:
Insurance Company Phone #:
Policy#:
Plan#:
Section 2: Medicaid/Medicare Insurance:
Recipient I.D #:
Date Issued:
UNCC - Summer 2014
4
2014 Summer Residential Enrichment Programs
STUDENT RELEASE FORM
TO BE COMPLETED BY STUDENT AND PARENT/GUARDIAN
Disabilities/Dietary Restrictions Accommodations Information
We recognize that students may have documented disabilities covered by state and federal laws or
dietary restrictions that may necessitate reasonable accommodations. Please help us by providing
information so that we can prepare reasonable accommodations for the student.
Information provided on this form will be treated with the greatest confidentiality.
If you have a disability, either physical or mental, that requires reasonable accommodation you
will need to provide documentation of the disability and the accommodation requested by the
health care provider. (For example, testing/note-taking or, physical accommodation needs, etc.)
Once reviewed, we will determine the accommodation.

No, I do not have a disability that requires reasonable accommodation. (If no, please go to
page 4).

Yes, I have a disability/dietary restriction that requires reasonable accommodation. (If yes,
please proceed with completing the remainder of this form.)
Please explain the nature of the disability or dietary restriction:
_________________________________________________________________________________
_________________________________________________________________________________
Please describe the reasonable accommodations that your health care provider requests and attach
the documentation:
_________________________________________________________________________________
_________________________________________________________________________________
UNCC - Summer 2014
5
2014 Summer Residential Enrichment Programs
STUDENT RELEASE FORM
TO BE COMPLETED BY STUDENT AND PARENT/GUARDIAN
Rules and Regulations - Honor Code and Behavior Expectations
GEAR UP North Carolina Enrichment is a multi-day commitment where student participants strive
for excellence in his/ her personal development. As a student participant in a GEAR UP North
Carolina Enrichment Program, you are expected to adhere to high standards of conduct at all times
and to accept personal responsibility for your conduct. You are responsible for your behavior during
the entire program and you are expected to be honest, fair, civil, and respectful of people and
property. In addition to these rules, you must also adhere to your own school’s rules of conduct.
You and your parent/guardian must pay for any damage to buildings, equipment or college site
property that you cause. Inappropriate behavior or violation of rules may result in disciplinary
action and possible dismissal from the program.
GEAR UP Enrichment Program expects that all students will:
 Respect and follow the directions of counselors, facilitators, and all other adults in
supervisory positions.
 Be conscious of your/others safety. Remain in groups of at least 2 at all times.
 Always let counselors know where you are.
 Have acceptable noise levels at all times, including while in the residence hall, campus
buildings and restrooms.
 Dress appropriately at all times. Bare midriffs, halter tops, or spaghetti straps are not
allowed. In addition, shoes are required in all areas of campus.
 Adhere to the assigned schedule of events in a timely manner and that lights are turned out
when designated.
 Participate in the scheduled indoor/outdoor recreation, unless a restriction is indicated.
 Be held accountable for the decisions made regarding your behavior and actions while
taking part in the GEAR UP North Carolina program.
Prohibited Activities
Students who engage in the following actions may be immediately dismissed from the GEAR UP
North Carolina Summer Enrichment program:
 Dishonesty, theft, destruction of property, and fighting.
 Possession of matches, lighters, or any other incendiary device.
 Tampering with fire alarms, extinguishers, or hoses.
 Possession, sale, or use of alcohol, tobacco products, illegal drugs, or improperly obtained
prescription drugs.
 Possession of weapons of any kind including all guns, all knifes, all explosive and/or any
other implement that could be used as a weapon.
 Violation of any State and/or Federal laws.
 Violation of rules of UNC General Administration or your school.
 Failure to obey any rules or following instructions imposed adults in supervisory positions.
 Visiting or having visitors in a dormitory room without written permission of chaperones or
supervisory facilitators.
 Reckless, disruptive, risky, or damaging behavior, fighting, verbal, or physical harassment of
students or staff.
 Traveling outside of the designated site boundaries.
 Other behavior that, in the sole judgment of the site coordinator or GEAR UP staff, is
contrary to the educational goals of the program.
UNCC - Summer 2014
6
2014 Summer Residential Enrichment Programs
STUDENT RELEASE FORM
TO BE COMPLETED BY STUDENT AND PARENT/GUARDIAN
Rules, Regulations, & Program Arrangements
I understand that although GEAR UP will attempt to implement the program as described in
its documentation, it reserves the right to change the program if necessary to promote
program objectives, safety issues, or institutional needs.
I understand that the student participants will be transported to the university by a school
district bus OR that the student participants will be transported to an agreed- upon meeting
location by a school district bus and transported to the university by a charted bus.
Students may also be transported to the university or to an agreed-upon meeting location
for a charted bus by a parent or chaperone at the sole discretion of each student’s
parent/guardian.
I have carefully read, understand, and fully agree to abide by this agreement with the
GEAR UP North Carolina Enrichment Program and through one or more of the listed
universities: Winston-Salem State University, UNC Greensboro, Elizabeth City State
University, Fayetteville State University, NC State University, or UNC Charlotte. I will be
responsible for myself and my property. This agreement supersedes any previous or
contemporaneous understandings I may have had with the program and its agents,
whether oral or written.
Signed: _____________________________________ Date: ______________________
Parent/Guardian’s signature
Signed: _____________________________________ Date: ______________________
Student’s signature
UNCC - Summer 2014
7
2014 Summer Residential Enrichment Programs
STUDENT RELEASE FORM
TO BE COMPLETED BY STUDENT AND PARENT/GUARDIAN
Authorization for Medical Treatment and Hold Harmless
This must be signed by parent/guardian prior to the student’s participation in the
GEAR UP North Carolina Summer Enrichment Program.
Please read carefully before signing.
I, the undersigned, hereby certify that I am the parent/legal guardian of ______________
____________________________ (please print student’s name). I hereby give permission
for GEAR UP North Carolina Enrichment Program (“Program”) to seek appropriate medical
attention for the student in the event of accident, injury, or illness while in attendance at
the Program. I will be responsible for any and all costs of medical attention and treatment.
I fully understand that this program will expose my child to many health and safety risks
associated with travel and participation in the program. I fully accept this possibility of risks
and assume all risks associated with this program.
I therefore agree to release, hold harmless discharge, and indemnify the GEAR UP North
Carolina Summer Enrichment Program, the UNC-General Administration, the UNC Board of
Governors, University Officials, employees, agents and volunteers from any present or
future liability, claim or demand that may be asserted in connection with (a) emergencies,
accidents, illnesses, injuries, or other consequences or events arising from my child’s
participation in the Program, (b) any cause, event or occurrence beyond the direct control
of the Program including, but not limited to, natural disasters, terrorists acts or the
negligence of other persons, and (c) events or occurrences caused by your child’s behavior
or conduct while traveling and participating in the Program. Further, I understand and agree
that this acknowledgement, discharge, hold harmless agreement, release, indemnification
and assumption of risk shall be binding on me, my heirs, my assigns, members of my family,
my executors and administrators and my personal representative.
Signed: _____________________________________ Date: ______________________
Parent/Guardian’s signature
Signed: _____________________________________ Date: ______________________
Student’s signature
UNCC - Summer 2014
8
2014 Summer Residential Enrichment Programs
STUDENT RELEASE FORM
TO BE COMPLETED BY STUDENT AND PARENT/GUARDIAN
Photo Release Information
In consideration of our desire to participate in a project which I believe will be of
educational benefit, I grant to GEAR UP North Carolina Enrichment Program the absolute
right and permission to make motion pictures/audio or still photographs of the student I
also give the Program and/or its licensees the permission to copyright, televise, publish and
otherwise use and distribute these photographs and pictures. I also waive any right that I
may have to inspect and/or approve the finished product or the advertising copy that may
be used in connection with these photographs or pictures or the use to which it may be
applied. I further release the Program from any and all claims by me or my child for libel,
slander, invasion of privacy, and or any claim by me or my child based on the use of said
work.
The GEAR UP North Carolina Enrichment Program requests this permission in order to
produce materials to be used documenting the activities of the program, advertising and
promoting the program, and recruiting new students into the program.
Signed: _____________________________________ Date: ______________________
Parent/Guardian’s signature
Signed: _____________________________________ Date: ______________________
Student’s signature
UNCC - Summer 2014
9
2014 Summer Residential Enrichment Programs
STUDENT RELEASE FORM
TO BE COMPLETED BY STUDENT AND PARENT/GUARDIAN
Parent/Guardian Consent
The GEAR UP North Carolina Enrichment Program will allow students to experience inside
and outside skill building exercises to prepare them for college. They will participate in
physical and mental tasks that emulate the challenge and rewards of college life. Students
will not be allowed to participate unless parental permission is granted. Before signing this
consent form, please review the expected Schedule of Events. Although we strongly
encourage your child’s involvement, if there is an event you do not want them to
participate in, please record it below. For any questions or concerns about these events,
please contact the GEAR UP North Carolina State Office at (919) 843-5875 or (919) 9624208 or your child’s GEAR UP Coordinator or Facilitator in the school district.
I, the undersigned, being the parent/legal guardian of ___________________________,
(Print Student name)
give permission for my student to participate in all events (please sign below).
OR
I, the undersigned, being the parent/legal guardian of ___________________________,
(Print Student name)
give permission for my student to participate in only the following events (please sign
below):
__________________________________________________________________
_________________________________________
_____________________
Parent/Legal Guardian’s Signature
Date
UNCC - Summer 2014
10
GEAR UP Summer 2014 Residential Program
PARENTAL CONTACT AND PERMISSION RELEASE FORM
This form is to be completed and signatures provided in its entirety as a requirement for participation in the GEAR
UP NC Summer Residential program to which the student has been accepted. It is the expectation that the legal
parent or guardian will complete this form. However, if this is not possible, please attach a detailed explanation of
an exception.
Return the completed form postmarked on or before December20th
2013 to:
Mrs. Shagufta Raja, MSEN Coordinator
The University of North Carolina at Charlotte
College of Education Bldg., Suite 222
9201 University City Blvd.
Charlotte, NC 28223-0001
1. CONTACT INFORMATION
It is critical that GEAR UP NC personnel be able to contact a parent, guardian, or designated representative at
all times during the period that a student is attending the GEAR UP residential program. This may be necessary
for two reasons.
First, the GEAR UP staff may need to contact a parent if the student faces a major medical emergency. Second, in
case of student dismissal, an adult must be available to remove the student from the campus of the host institution
immediately.
Student Information:
First Name
Middle
Street Address
Last Name
Preferred Name
Home Phone Number
Cell Number
City/State/Zip Code
Email Address
With whom does the student reside?
Parent/Guardian Information:
Name
(
Relationship to Student
)
(
)
Work Phone Number
Cell Phone Number
Name
(
Relationship to Student
)
(
)
Work Phone Number
Cell Phone Number
Name
(
Email Address
Email Address
Relationship to Student
)
Work Phone Number
(
)
Cell Phone Number
Email Address
We will utilize email communication to parent(s)/guardian and the student as much as possible
throughout the program. Please indicate only those email addresses that are actively used and are
suitable to receive GEAR Up information.
UNCC - Summer 2014
Please print all information. Thank you.
11
If the parent(s)/guardian will have a different Summer Address than the one listed on page 1, please
provide this information:
Name
(
Street Address
)
Phone Number
City/State/Zip
Expected Dates to be at this Address
If the student must leave the program for any reason and you cannot be reached, there must be another
adult available (not a parent/guardian) who will take responsibility for removing the student from
campus.
Name
Relationship to Student/Family
(
)
Street Address
Home Phone Number
(
)
City/State/Zip
Work Phone Number
(
)
Cell Phone Number
I,
accept responsibility for
(Above-named adult)
(Name of student)
in the event the parent/guardian cannot be reached.
Signature
(Above-named adult)
Date
I authorize the above-named adult to take charge of my son/daughter (the student) if he/she must leave the
GEAR UP Program and I cannot be reached:
Parent/Guardian signature
Date
2. CUSTODY INFORMATION
This section is to be completed only if the student’s parents are separated or divorced, or if the student is
living with a legal or custodial guardian. Please provide the following information so requests for visits
and other situations can be handled in a proper manner.
In the case of a student whose parents are separated or divorced, does the other parent have visitation
rights?
Yes
No
If yes, are these such as to allow the other parent to visit the student at GEAR UP? Yes
No
In the case of a student who is living with a legal or custodial guardian, do the birth parents have
visitation rights?
Yes
No
If yes, are these such as to allow the birth parents to visit the student at GEAR UP? Yes
UNCC - Summer 2014
Please print all information. Thank you.
No
12
3. INCIDENTAL COSTS AND MEDICAL INSURANCE
We understand that although tuition, room, board, and fees are provided free of charge the student’s
family or guardian must assume responsibility for a medical examination and any necessary
immunizations for the student prior to enrollment, transportation to and from the site, including break
weekend, pocket money for student’s incidental personal expenses, and payment for any medical
expenses incurred by the student during the institute. Check one of the following and sign below:
The student is not covered by medical insurance. I will assume responsibility for any medical
expenses he or she incurs during participation in GEAR UP.
The student is covered by medical insurance. (Information provided on the Medical Form.)
Read the following statement and sign below:
I accept the arrangements as stated in #3 “Incidental Costs and Medical Insurance”.
Parent/Guardian signature
Date
4. MEDICAL RELEASE
During the GEAR UP Summer Program, routine medical care will be provided as needed by the
infirmary/health services of the host campus, which also will administer first aid in case of an accident
occurring on campus. Parents/guardians will be informed of any medical treatment the student has
received.
Read the following statements and sign below:
I accept the arrangement as stated in #4 “Medical Release”. In case of a major medical emergency, such
as acute appendicitis or serious injury, I hereby authorize any medical treatment which may be advised
or recommended by attending medical personnel for my son/daughter/ward. Where practical, I will be
notified by telephone before any procedures are done.
Parent/Guardian signature
Date
5. Property Damage Responsibility
Read the following statement and sign below:
I understand that my son/daughter is responsible for any damage he or she may incur on the property of
UNC Charlotte campus or during extracurricular activities. I will assume responsibility for the cost of
repairing any damage incurred by the student during participation in the Gear UP NC program.
Parent/Guardian signature
UNCC - Summer 2014
Date
Please print all information. Thank you.
13
6. Field trip Permission
GEAR UP intends to provide its members with opportunities away from the facility. On field trips,
members are transported in rented vehicles, school buses or public transportation. On some occasions, they
may walk. If you sign in the space below, your child will be allowed to participate in these field trips during
normal program hours, and you are also giving permission for your daughter to ride in vehicles used by the
Gear Up program. Program staff will inform you about the destination, departure time and arrival times, as
well as special instructions to prepare for the field trip including any cost involved. NC MSEN Pre-College
at UNC Charlotte nor any of its affiliated individuals and organizations are responsible for any injury
sustained by a program participant on field trips.
____________
Date
Parent/guardian signature
7. Internet Use Policy and Permission form
Participants of GEAR UP will utilize the internet as a tool for learning and growth. Emailing may be
permitted at designated times and monitored closely by staff and volunteers as part of programming.
GEAR UP may block certain websites from students. Participants are not permitted to visit websites or send
electronic mail that contains ethnic slurs, racial epithets, or anything that may be construed as harassment or
belittling of others based on their sex, race, national origin, age, disability, or religion.
GEAR UP reserves the right to determine when a student is sending excessive or improper electronic mail.
Transmission of any material in violation of any national or state regulation is prohibited. This includes but
is not limited to: copyrighted materials, threatening or obscene materials or material protected by trade
secret.
By signing below, I understand the internet policies listed above and agree to encourage my child to
abide by them.
Parent Signature: _________________________
Date: ________________________
Print Name: ______________________________
Student Name: ________________
8. RELEASE OF INFORMATION
We agree to let applicant information and other records shared with the GEAR UP program in approved
research and used in aggregate reports. Further, we agree that the student will participate in the
completion of questionnaires as part of the program’s evaluation.
We also agree that photographs of the student taken during the program, papers written by the student
during the program, and similar items may be used by GEAR UP in reports and public information
materials. We further agree to allow GEAR UP to release for educational purposes, photographs and
video recordings, with or without audio, of GEAR UP activities and projects involving the student.
We agree: 1. the directory information about the student, including student’s name and address, school,
year in school, and parents’ names and address may be released at the discretion of the GEAR UP
administrative staff to other educational programs that would like to send brochures and application forms
to GEAR UP applicants and 2. Information may be used in press releases, student directories, and similar
publications.
UNCC - Summer 2014
Please print all information. Thank you.
14
Please check one and sign below.
We agree to the release of information as described in this section.
We disagree to the release of information as described in this section which may not allow the student to
participate in GEAR UP residential program.
Parent/Guardian signature
Date
9. GENERAL PERMISSION AND LIABILITY RELEASE
All GEAR UP programs include a variety of activities, including laboratories, field trips, and sports. In
all activities, care is taken that all safety procedures are followed, proper instruction given, and adequate
supervision provided. Students with physical handicaps are excused from inappropriate activities.
Read the following statements and sign below:
I understand that GEAR UP includes a wide range of activities as described above and grant permission
for my son/daughter (the student) to participate in these activities. I discharge and release the University
of North Carolina, its constituent campuses, GEAR UP Program, and their employees and agents from
any claims or liability that may arise because of personal danger or injury, property damage or loss, or
loss of life, either suffered by my son/daughter/ward or caused by him or her to any third party, which
may result from or have its origin in participation in GEAR UP, including but not limited to field work,
laboratories, recreational activities, and off-campus trips.
Parent signature
Date
10. ACCEPTANCE OF REGULATION
Read the following statement and sign below
We, the student and parent/guardian, have read the Statewide Student Policies of GEAR UP NC and
hereby accept the regulations of the Program described therein. We understand that each campus has
the authority to establish and enforce other regulations in addition to these.
We understand that failure to abide by statewide or local regulations may lead to the student’s dismissal
from the Program. We understand that the Director of the institute has the authority to dismiss the student
for behavior that is not specifically covered in the regulations, but which is contrary to the educational
goals of the GEAR UP Program. Finally, we understand that in the case of violations covered by state
law, GEAR UP staff is legally required to report the violations to local law officials for handling.
Parent/Guardian Name (Print)
Parent/Guardian signature
UNCC - Summer 2014
Student Name (Print)
Date
Student signature
Please print all information. Thank you.
Date
15
GEAR UP Summer 2014 Residential Program
PARENTAL CONTACT AND PERMISSION RELEASE FORM
This form is to be completed and signatures provided in its entirety as a requirement for participation in the UNC
Charlotte (UNCC) GEAR UP NC Summer Residential program to which the student has been accepted. It is the
expectation that the legal parent or guardian will complete this form. However, if this is not possible, please attach
a detailed explanation of an exception. For additional questions, please see the UNCC program’s contact
information below:
Mrs. Shagufta Raja, MSEN Coordinator
The University of North Carolina at Charlotte
College of Education Bldg., Suite 222
9201 University City Blvd.
Charlotte, NC 28223-0001
1. CONTACT INFORMATION
It is critical that UNCC personnel be able to contact a parent, guardian, or designated representative at all times
during the period that a student is attending the UNCC GEAR UP residential program. This may be necessary
for two reasons.
First, the UNCC staff may need to contact a parent if the student faces a major medical emergency. Second, in case
of student dismissal, an adult must be available to remove the student from the campus of the host institution
immediately.
Student Information:
First Name
Middle
Street Address
Last Name
Preferred Name
Home Phone Number
Cell Number
City/State/Zip Code
Email Address
With whom does the student reside?
Parent/Guardian Information:
Name
(
Relationship to Student
)
(
)
Work Phone Number
Cell Phone Number
Name
(
Relationship to Student
)
(
)
Work Phone Number
Cell Phone Number
Name
(
Email Address
Email Address
Relationship to Student
)
Work Phone Number
(
)
Cell Phone Number
Email Address
We will utilize email communication to parent(s)/guardian and the student as much as possible
throughout the program. Please indicate only those email addresses that are actively used and are
suitable to receive GEAR Up information.
UNCC - Summer 2014
Please print all information. Thank you.
16
If the parent(s)/guardian will have a different Summer Address than the one listed on page 1, please
provide this information:
Name
(
Street Address
)
Phone Number
City/State/Zip
Expected Dates to be at this Address
If the student must leave the program for any reason and you cannot be reached, there must be another
adult available (not a parent/guardian) who will take responsibility for removing the student from
campus.
Name
Relationship to Student/Family
(
)
Street Address
Home Phone Number
(
)
City/State/Zip
Work Phone Number
(
)
Cell Phone Number
I,
accept responsibility for
(Above-named adult)
(Name of student)
in the event the parent/guardian cannot be reached.
Signature
(Above-named adult)
Date
I authorize the above-named adult to take charge of my son/daughter (the student) if he/she must leave the
UNCC GEAR UP Program and I cannot be reached:
Parent/Guardian signature
Date
2. CUSTODY INFORMATION
This section is to be completed only if the student’s parents are separated or divorced, or if the student is
living with a legal or custodial guardian. Please provide the following information so requests for visits
and other situations can be handled in a proper manner.
In the case of a student whose parents are separated or divorced, does the other parent have visitation
rights?
Yes
No
If yes, are these such as to allow the other parent to visit the student at UNCC?
Yes
No
In the case of a student who is living with a legal or custodial guardian, do the birth parents have
visitation rights?
Yes
No
If yes, are these such as to allow the birth parents to visit the student at UNCC?
Yes
UNCC - Summer 2014
Please print all information. Thank you.
No
17
3. INCIDENTAL COSTS AND MEDICAL INSURANCE
We understand that although tuition, room, board, and fees are provided free of charge the student’s
family or guardian must assume responsibility for a medical examination and any necessary
immunizations for the student prior to enrollment, transportation to and from the site, including break
weekend, pocket money for student’s incidental personal expenses, and payment for any medical
expenses incurred by the student during the institute. Check one of the following and sign below:
The student is not covered by medical insurance. I will assume responsibility for any medical
expenses he or she incurs during participation in the UNCC summer program.
The student is covered by medical insurance. (Information provided on the Medical Form.)
Read the following statement and sign below:
I accept the arrangements as stated in #3 “Incidental Costs and Medical Insurance”.
Parent/Guardian signature
Date
4. MEDICAL RELEASE
During the UNCC GEAR UP Summer Program, routine medical care will be provided as needed by the
infirmary/health services of the host campus, which also will administer first aid in case of an accident
occurring on campus. Parents/guardians will be informed of any medical treatment the student has
received.
Read the following statements and sign below:
I accept the arrangement as stated in #4 “Medical Release”. In case of a major medical emergency, such
as acute appendicitis or serious injury, I hereby authorize any medical treatment which may be advised
or recommended by attending medical personnel for my son/daughter/ward. Where practical, I will be
notified by telephone before any procedures are done.
Parent/Guardian signature
Date
5. Property Damage Responsibility
Read the following statement and sign below:
I understand that my son/daughter is responsible for any damage he or she may incur on the property of
UNC Charlotte campus or during extracurricular activities. I will assume responsibility for the cost of
repairing any damage incurred by the student during participation in the UNCC GEAR UP NC program.
Parent/Guardian signature
UNCC - Summer 2014
Date
Please print all information. Thank you.
18
6. Field trip Permission
UNCC intends to provide its members with opportunities away from the facility. On field trips, members
are transported in rented vehicles, school buses or public transportation. On some occasions, they may walk.
If you sign in the space below, your child will be allowed to participate in these field trips during normal
program hours, and you are also giving permission for your daughter to ride in vehicles used by the Gear Up
program. Program staff will inform you about the destination, departure time and arrival times, as well as
special instructions to prepare for the field trip including any cost involved. NC MSEN Pre-College at UNC
Charlotte nor any of its affiliated individuals and organizations are responsible for any injury sustained by a
program participant on field trips.
____________
Date
Parent/guardian signature
7. Internet Use Policy and Permission form
Participants of the UNCC GEAR UP program will utilize the internet as a tool for learning and growth.
Emailing may be permitted at designated times and monitored closely by staff and volunteers as part of
programming.
UNCC may block certain websites from students. Participants are not permitted to visit websites or send
electronic mail that contains ethnic slurs, racial epithets, or anything that may be construed as harassment or
belittling of others based on their sex, race, national origin, age, disability, or religion.
UNCC reserves the right to determine when a student is sending excessive or improper electronic mail.
Transmission of any material in violation of any national or state regulation is prohibited. This includes but
is not limited to: copyrighted materials, threatening or obscene materials or material protected by trade
secret.
By signing below, I understand the internet policies listed above and agree to encourage my child to
abide by them.
Parent Signature: _________________________
Date: ________________________
Print Name: ______________________________
Student Name: ________________
8. RELEASE OF INFORMATION
We agree to let applicant information and other records shared with the UNCC program in approved
research and used in aggregate reports. Further, we agree that the student will participate in the
completion of questionnaires as part of the program’s evaluation.
We also agree that photographs of the student taken during the program, papers written by the student
during the program, and similar items may be used by UNCC in reports and public information materials.
We further agree to allow UNCC to release for educational purposes, photographs and video recordings,
with or without audio, of UNCC activities and projects involving the student.
We agree: 1. the directory information about the student, including student’s name and address, school,
year in school, and parents’ names and address may be released at the discretion of the UNCC
administrative staff to other educational programs that would like to send brochures and application forms
UNCC - Summer 2014
Please print all information. Thank you.
19
to GEAR UP applicants and 2. Information may be used in press releases, student directories, and similar
publications.
Please check one and sign below.
We agree to the release of information as described in this section.
We disagree to the release of information as described in this section which may not allow the student to
participate in GEAR UP residential program.
Parent/Guardian signature
Date
9. GENERAL PERMISSION AND LIABILITY RELEASE
All UNCC programs include a variety of activities, including laboratories, field trips, and sports. In all
activities, care is taken that all safety procedures are followed, proper instruction given, and adequate
supervision provided. Students with physical handicaps are excused from inappropriate activities.
Read the following statements and sign below:
I understand that the UNCC GEAR UP program includes a wide range of activities as described above
and grant permission for my son/daughter (the student) to participate in these activities. I discharge and
release the University of North Carolina, its constituent campuses, GEAR UP Program, and their
employees and agents from any claims or liability that may arise because of personal danger or injury,
property damage or loss, or loss of life, either suffered by my son/daughter/ward or caused by him or
her to any third party, which may result from or have its origin in participation in the UNCC GEAR UP
program, including but not limited to field work, laboratories, recreational activities, and off-campus
trips.
Parent signature
Date
10. ACCEPTANCE OF REGULATION
Read the following statement and sign below
We, the student and parent/guardian, have read the Statewide Student Policies of UNCC and hereby
accept the regulations of the Program described therein. We understand that each campus has the
authority to establish and enforce other regulations in addition to these.
We understand that failure to abide by statewide or local regulations may lead to the student’s dismissal
from the Program. We understand that the Director of the institute has the authority to dismiss the student
for behavior that is not specifically covered in the regulations, but which is contrary to the educational
goals of the UNCC GEAR UP Program. Finally, we understand that in the case of violations covered by
state law, UNCC staff is legally required to report the violations to local law officials for handling.
Parent/Guardian Name (Print)
Parent/Guardian signature
UNCC - Summer 2014
Student Name (Print)
Date
Student signature
Please print all information. Thank you.
Date
20