ALL STEM Required forms update 12 Mar 2012 by HC12051903625

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									  Naval Academy Summer STEM Accept/Decline Form

I, _________________________________________________ (student’s name)
ACCEPT/DECLINE (circle one) my offer to attend the Naval Academy Summer STEM
Program.

All Summer STEM Program registration forms and documents must be postmarked no
later than May 11th, 2012. No extensions will be granted. If you do not respond by this
date, your selection for the Summer STEM Program will be canceled and your seat will
be offered to another student.

Please return this form to: United States Naval Academy
                            Office of Admissions
                            ATTN: STEM
                            117 Decatur Road
                            Annapolis, MD. 21402-5017

A confirmation letter will arrive approximately two weeks after we receive your tuition
payment.




The following documents must be returned to complete registration:

        Accept/Decline Form (this page)
        Power of Attorney
        Media Release Form
        Yard Patrol Liability
        STEM Travel Worksheet


Check box to indicate completion:

        Online Payment & Date Submitted______________
                            YARD PATROL LIABILITY FORM

EVENT: 2012 USNA SUMMER STEM DATE OF EVENT: JUNE 2012

In consideration of my request to tour/embark a Yard Patrol craft or other Naval Academy vessel, I,
the undersigned intending to be legally bound, hereby waive myself, parents, guardians, heirs,
executors, assigns and administrators any and all rights and claims for damages, demands, and
other actions whatsoever, including that which I may have against any of the following entities: the
U.S. Naval Academy, Annapolis, Maryland; the Department of the Navy; the Department of Defense;
the United States Government; all U.S. Naval Academy military and civilian personnel; plus, all
participating supporters and personnel provided; and these entities’ representatives, successors and
assigns, arising out of my participation in this event, including any and all injuries or illnesses
suffered by me as a result of my participation in this event or use of any U.S. Naval Academy or
government facilities or equipment or vessel in conjunction with my participation. I further verify that
I have full knowledge of the risks involved in participation in events of this nature where marine craft
are used. By participating in this event, I hereby permit the above-mentioned entities to utilize my
name or likeness for any purpose whatsoever.

I also understand that I am responsible for my conduct while aboard the Navy vessel to which I am
assigned. I am further aware that no alcoholic beverages of any type are allowed aboard any Navy
marine craft, and that any misuse of equipment or its facilities will result in revocation of my
privileges to participate in this or any future marine event at the U.S. Naval Academy.

Additionally, I understand that if I cannot swim, it is in my best interest to wear a Type III U.S. Coast
Guard approved Personal Flotation Device (PFD) at all times while onboard Navy vessels.

If Under Age 18: I, the understood parent or lawful guardian of the below-named person, do hereby
grant my permission and consent for my child to participate in the above-described event. I have
read and agree to be bound by the above-mentioned terms. I understand that my child must be at
least 8 years of age and must have a Type III U.S Coast Guard PFD on the day of the event.


NAME:_______________________________



SIGNATURE (or parent/guardian signature if under 18):


______________________________________________ DATE: ___________________
U.S. NAVAL ACADEMY SCIENCE TECHNOLOGY ENGINEERING &
MATHEMATICS (STEM) SPORTS PARTICIPATION AND MEDICAL
POWER OF ATTORNEY

PRIVACY ACT STATEMENT

Authority:   5 USC 301, 44 USC 3101, E.O. 9397
Purpose:     To obtain parental or legal guardian consent for participation in recreational/
             physical activities and medical diagnosis and treatment while attending the Naval
             Academy Summer Seminar.
Uses:        To authorize participation in recreational/physical activities and decide upon and
             consent to medical diagnosis and treatment, including surgery, deemed to be in the
             best interest of your child.

IMPORTANT: YOU MUST FILL OUT BOTH SIDES OF THIS FORM. Disclosure is
voluntary. However, failure to provide the requested information may prevent your child
from participating in the recreational phase of the STEM.

I. GENERAL INFORMATION (PLEASE PRINT)

   Student information to be completed by parent(s) or guardian(s):

   Name (Last, First, Middle Initial):______________________________________________

   Date of Birth (Day, Month, Year):____________________________________________

   Home Address:______________________________________________________

   Parent/Guardian Phone Number (Home):(____)_________(Work):(____)___________

II. SPORTS PARTICIPATION

I give consent for the above named student to participate in all recreational and physical
activities that may be arranged for STEM attendees, and I further certify that he/she is in good
health and is capable of withstanding the rigors of physical exercise. I acknowledge that
persons who may use the facilities of the United States Naval Academy do so at their own risk
and that employees and agencies of the U.S. government and/or the U.S. Naval Academy are
not responsible for loss of personal property, injury, or loss of life.

Printed Name of Parent or Guardian _______________________________________
Signature of Parent or Guardian____________________________ Date __________



YOU MUST FILL OUT BOTH PAGES OF THIS FORM!
III. GENERAL INFORMATION ABOUT CHILD
Existing medical problems, allergies, medications currently taking:
___________________________________________________________________________
___________________________________________________________________________
Insurance Company: __________________________________________________________
Policy Number:_______________________________________________________________
Other information you would like us to know about your child: __________________________
___________________________________________________________________________

IV. MEDICAL POWER OF ATTORNEY
We (I) ____________________________________________ (name(s) of parent(s) or guardian)
of _________________________________________________________ (residential address in
full) do hereby appoint the following commissioned officers and senior staff assigned to the Office
Of Admissions at the U.S. Naval Academy, Annapolis, Maryland:
         Dean Bruce Latta                  CAPT Angela Cyrus                LCDR Damon Myers
         LtCol Jim Hanley, USAF (ret)      LT William Christian             Ms. Karin Dolan
         LT Anna Latorre                   LT Thomas Dotstry                Capt James Smith
         LT Christina Adams                LT Sean James                    LTJG Angelique Clark
         LT Aaron Obrochta                 LT John Malone                   LT Landerrick Bolding
         LT Eddie Carthan                  LT Rachel Walker                 LT Emily Laraway
         LT Christopher Reyes              LT Mikaela Rodkin                LT Jeremy Biggs
         HM1 Kawika Segundo                HM1 Charles Ramirez


our true and lawful attorneys in fact, with full power in loco parentis for the sole purpose of
deciding upon and consenting to the rendering of any medical diagnosis and treatment, including
surgery, which any one of said attorneys deems in the best interest of the health and welfare of
our child, _________________________________ (name of child). This power of attorney shall be
effective during such period of time as we, or either of us, may for any reason not be available to
give our consent to any medical diagnosis or treatment, including surgery, for our child for the
time period 4 June to 23 June 2012 inclusive.

This power of attorney shall not be affected by the disability of either or both of us, but it shall
continue in full force and effect during any such disability.

Executed this _______ day of ___________ 2012.

_________________________                                      _________________________
    Signature of Parent/Guardian                                  Printed Name of Parent/Guardian

Before the undersigned, a licensed notary public came the above named person who provided
me with valid and suitable identification and signed the said form in my presence on the dated
noted above.

_________________________                                       _________________________
    Signature of Notary Public                                    Printed Name of Notary Public

My Commission expires:     __________
                                                                                Notarial Seal
                          MEDIA RELEASE FORM

I, ______________________(student name) am visiting the United States Naval
Academy participating in the 2012 Summer STEM program, Session ____,
between the dates of (Session One: 4-9 June; Session Two: 11-16 June; and
Session Three: 18-23 June). The visit schedule entails attending academic
classes, participating in physical training, leadership exercises and field trips.

Throughout the duration of each session of Summer STEM, there are
opportunities for photographic and video coverage of the candidates participating
in the Summer STEM activities, which include physical training and leadership
exercises. These photos could be used for media coverage of this event, as well
as for promotional materials to assist the Naval Academy in marketing to high
school and middle school students.

I hereby give my permission for photographic and video coverage by USNA staff
of my involvement and participation in these activities. If under the age of 18,
parent/legal guardian signature required.

Please send completed form back to the USNA Office of Admissions.

United States Naval Academy
Office of Admissions
ATTN: STEM
117 Decatur Road
Annapolis, MD 21402-5017



                          _____________________________

                          Signature and Date
                          (if under the age of 18, parent and/or legal guardian)

								
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