Discovery Healthcare High School Registration

Parent/Guardian Information

Student Information

The following four (4) fields must be completed.

If any of these do not apply to you, please type “not applicable”.

School Information

Emergency Contact Information

INFORMED CONSENT AGREEMENT

I/We the undersigned, hereby acknowledge that certain risks of injury are inherent to participation in hands-on camp activities. These types of injuries may be minor or serious and may result from one’s own actions, or the actions of others, or a combination of both. I/We understand that the rules and regulations are designed for the safety and protection of participants and hereby undertake that my child will abide by these rules and regulations. I/We hereby warrant that my/our child is physically fit to participate and understand that the choice to participate brings with it the assumption of those risks and results which are part of these activities. I/We agree that the Governing Council of the University of Western Ontario, their directors, officers, employees, students, and volunteers, shall not be liable for any injury to my child or loss or damage to my child’s personal property arising from, or in any way resulting from, his/her participation in those activities, unless such injury, loss or damage is caused by the sole negligence of the University, their directors, officers, employees, students, and volunteers, while acting within the scope of their duties. I/We agree to allow my child to receive basic first aid/ medical care from instructors certified in first aid or trained medical professionals if necessary. I/We declare having read and understood the above Informed Consent Agreement in its entirety and hereby consent to participate acknowledging all the foregoing. I/We also certify that the information provided in this form is, to my/our knowledge, true and complete.

BLOOD TYPING

Some camps will have the opportunity to run pathology labs where students will have the option to participate in a test that will provide their blood type. This test requires a finger prick to retrieve a small blood sample. Participating is voluntary and results will not be stored by Western University. Consent can be withdrawn by the camper or parent/guardian at any time. If you have any concerns, please contact our office at distributed.education@schulich.uwo.ca

CODE OF CONDUCT

Discovery Healthcare is dedicated to fostering a safe and welcoming environment that is committed to celebrating all differences among our participants. In order to provide a respectful and inclusive environment, Discovery Healthcare has implemented a Code of Conduct to ensure the well-being of each participant.

As participants at Discovery Healthcare you have the right to feel safe and supported by your fellow participants and program staff. You have the right to be treated with respect, and in return you must treat others with respect. To help ensure all fellow participants are treated with dignity, all participants must follow the Code of Conduct.

PARTICIPANTS MUST

• Follow the camp rules and directions of program staff
• Participants must show respect for themselves, fellow participants, program staff, and community members. Bullying will NOT be tolerated.
• Use respectful language (for example, no swearing, racial or offensive comments)
• Take responsibility for your actions, words and belongings
• Remain with their group and counsellors when at public and community facilities
• Talk to a counsellor if they feel unsafe in any way
• Remain at the camp venue for the duration of camp and are not able to go offsite for lunch

PARTICIPANTS MUST NOT

• Threaten or intimidate another person
• Cause injury of any sort or encourage others to inflict harm to any other participant or program staff
• Trespass, steal, vandalize or cause damage of any sort to the program equipment, community facilities or other participant’s belongings
• Use foul, abusive or inappropriate language

PRIVACY POLICY

Schulich Medicine Distributed Education collects the personal information of program participants and their parents or guardians under the authority of The University of Western Ontario Act, 1982, as amended, and uses it to process applications and administer and operate safe and organized programs for our participants. Schulich Medicine Distributed Education uses the information to register participants in the program as well as address potential health concerns. In the event of an emergency, we will disclose information to emergency medical personnel and to the emergency contact provided on your registration form. Photos and videos of children may appear on television, web sites, brochures, newspapers, posters and other media to promote Discovery Healthcare and/or The University of Western Ontario, unless you check the opt out box below. If you have any questions about Schulich School of Medicine & Dentistry’s collection, use or disclosure of personal information, please contact the Program Coordinator, Schulich Medicine Distributed Education at 519-661-2111 ext. 22101

MEDIA CONSENT