CPP/SDSU CoE Femineer® Day Camp Authorization Forms and Waivers

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* 1. First and Last Name of Camper

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* 2. Student Contact Information

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 3. Parent Contact Information

Name

Email Address

Phone Number

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* 4. Media Release Authorization & Waiver: Throughout the summer period, the media may visit the Femineer® Virtual camps to cover activities. The Femineer® Virtual Camps may also wish to use your camper’s likeness (photograph/video), voice, or work for educational or camp promotional reasons. These forms of media may include publications, posters, brochures, newsletters, the Femineer® Virtual Camp web site, a radio station, a Cable TV channel, or at community fairs. According to state law, a school must obtain parent/guardian permission before a camper’s photograph, voice, or work could be used by the media. I hereby waive all rights of privacy and/or compensation for me and my camper and give my permission to the Femineer® Virtual Camps and the media to use my camper’s likeness (photograph/video), voice, or work for educational purposes or Femineer® Virtual Camp promotion only.

Agree

Disagree

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* 5. 2022 Code of Conduct for your Femineer® Virtual Camper
The Cal Poly Pomona Femineer® Camps participants are expected to behave in a responsible and courteous manner at all times. These rules apply to all behavior on campus property and during virtual Femineer® Camp sponsored activities.
The following is specifically NOT allowed:
1. Aggressive play towards other Femineer® Camp participants or staff.
2. Abusive or inappropriate language, verbal or written, toward other Femineer® Camp participants or staff.
3. Inviting or meeting non-camp friends during Femineer® Virtual Camp classes or activities.
4. Use of unapproved electronic devices during camp sessions, activities, or events without Femineer® Camp staff consent.
5. The use of illicit substances.
6. Cyber bullying will not be tolerated.
I understand that if my camper does not follow the Code of Conduct as described, then she/he may be dismissed from the Femineer® Virtual camp without refund of tuition.

Agree

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* 6. Does your camper have any health problems or conditions, learning disabilities, emotional, or physical conditions that we should know of to assist us in providing the best Virtual camp experience for your camper? If your child requires additional assistance, please notify us in advance.

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* 7. List all known allergies (medication, food/dietary restrictions, other — include insect stings, hay fever, asthma, animal dander, etc). Also, describe reaction and management of the reaction. This will help with knowing what supplies we are unable to ship your camper.

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* 8. In case of a medical emergency, the camp will contact the parent/guardian

Emergency Contact #1 (other than parent):

Emergency Contact #1 Phone:

Emergency Contact #1 Relationship:

Emergency Contact #2 (other than parent):

Emergency Contact #2 Phone:

Emergency Contact #2 Relationship:

Camper's Physician:

Physician's Phone:

Physician's Address:

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* 9. The Femineer® Program is open to all schools for all students. California State Polytechnic University, Pomona, prohibits discrimination in employment, educational
programs, and activities on the basis of race, creed, color, religion, national origin, age, sex, pregnancy, disability, genetic information, status as a U.S. veteran, service
in the U.S. military, sexual orientation, gender identity, associational preferences, or any other classification that deprives the person of consideration as an individual.
The University also affirms its commitment to providing equal opportunities and equal access to University facilities. For additional information contact the Office of
Institutional Equality and Compliance Office number: 909-869-4646