University of Massachusetts Boston

Participant's Name: Parent/Guardian Name (print):

If you are applying to a youth program at the University of Massachusetts Boston, please complete and mail the completed application packet to the address below:

University of Massachusetts Boston
100 Morrissey Boulevard
Boston, MA 02125

Failure to complete all forms in the application may result in your child not being accepted into the youth program.

Policies and Guidelines – Pg. 3

Personal, Family, and Emergency Contact Information – Pgs. 5-6

Release Forms – Pg. 7

Health History Packet

I, the undersigned, hereby give my permission for my son/daughter to participate in all the activities of the Program at UMass Boston from the date of his/her acceptance throughout his/her involvement with the program.

We (participant and I) agree to support the administrative rules of the Program, the below referenced UMass Boston policies and guidelines, and to cooperate with the staff to our fullest extent.

Further, by signing below, I attest to the fact that all of the information provided by me or any other person on this application is true and complete to the best of my knowledge.

Permission to Participate: When you signed your child's medical form, you gave permission for your child to participate in all program activities. If you wish for your child to be restricted from any activity, please notify us in writing prior to your child's program session. Please note that it is not our policy to force any child to participate in an activity. We do our best to make the activity enjoyable so your child will wish to participate.

Medical Concerns: All participants are required to have a completed application packet including UMass Boston's health history, immunizations, consent to treat minor patients, and authorization to administer medication forms on file before the program begins. Please be sure that you complete these forms and that your child's healthcare provider has signed that a physical examination has been conducted within the last 24 months. Please provide us with as much information as possible concerning your child's medical history, allergies, medications, and any special needs. All medical forms must include an up-to-date immunization record and must be signed by a healthcare provider. If these forms are not received at least 3 weeks prior to the program start date your child may not be allowed to start the program.

Medication: Every effort should be made to administer routine medications at home in order to prevent disruption in your child's daily program activities. However, if your healthcare provider believes that it is in the best medical interest of your child to administer them during the program's hours, please submit the completed Authorization to Administer Medication form. A separate form must be completed for each medication. State law does not permit administration of medication during the program hours without written authority by the prescribing healthcare provider. Youth program participants are at no time allowed to carry any kind of medication, be administered medication without official written directive from the prescribing healthcare provider or take medication without direct youth program supervision.

Weather Adjustments: Whenever possible, we bring outdoor activities into air-conditioned facilities, or to cool, shaded areas. Our first concern is for your child's safety; therefore, we reserve the right to take the following actions in very hot weather: reduce physical activities, substitute outdoor activities for sedentary activities, and provide activities unrelated to your child's specialty (e.g., movies).

Inappropriate Behavior: UMass Boston reserves the right to dismiss any participant who acts in an inappropriate or detrimental manner including bullying, harassing, intimidating, or threatening to other individuals.

Medical Notification: It is our policy to notify you if your child becomes ill during the youth program or suffers an injury other than minor bumps, bruises or scrapes.

Valuables: We recommend that program participants not bring large sums of money or other valuables to UMass Boston. The University is not responsible for lost or stolen personal items.

Sunscreen: The use of sunscreen is highly recommended by University Health Services. It is best to apply sunscreen to your child before he or she leaves home in the morning. You may wish to send along additional sunscreen to be applied later in the day.

Inappropriate Behavior: UMass Boston reserves the right to dismiss any participant who acts in an inappropriate or detrimental manner including bullying, harassing, intimidating, or threatening to other individuals.

University Health Services reserves the right to limit or restrict a participant's ability to carry any item, or wear clothing, deemed to pose a safety risk to the individual and/or others while participating in the program. This includes, but is not limited to, weapons (whether real or fake), explosives, sharp objects (including medical devices), inappropriate clothing or clothing with graphics deemed to be offensive. If the participant or his/her parent or guardian refuses to abide by this policy the participant may be restricted from participation until the issue is resolved to the satisfaction of the University Health Services RN or representative. I agree to abide by the policy as stated above.

Name of Participant (first & last): Street Address: Apt. #: Name of School: Participant's Grade: Language Spoken at Home: Can the participant swim? Yes No

Parent/Guardian Name (first & last): Street Address: Apt. #: Check here if same as parent/guardian above. Name (first & last): Street Address: Apt. #: Relationship to Participant: Name (first & last): Street Address: Apt. #: Relationship to Participant:

Please include a copy of your child's health insurance card. If you cannot provide the requested health insurance card; please provide the following insurance information:

Insurance Carrier: Policy Number: Cardholder's Name:

PLEASE READ THE FOLLOWING RELEASES CAREFULLY AND PROVIDE A SIGNATURE FOR EACH SECTION BELOW.