DEED-PTE Manufacturing Camp Emergency, Medical and Primary Information Form
Prior to attending camp, must be signed and returned to (by mail or fax): Alyssa Klein, 1201 89th Ave. NE, Suite 220, Blaine, Minnesota 55434 Phone: 763-785-6497 or 763-785-3362 (ask for Irma) Fax: 763-785-3365 Your registration must include the completed and signed Waiver of Liability, Indemnification, and Medical Release Information below. Student’s Name Age (at time of camp) Student’s Social Security Number Address City Home Phone Email address High School: Grade for the 2007-08 year (circle one): 10th 11th 12th transition program graduated other: Other support persons (County case manager, Rehabilitation Services-VR counselor, etc.): Parent (if under age 18 or have legal guardianship assigned) or other emergency contact: Home Phone Email address 2nd Parent (or other adult emergency contact): Home Phone Email address ( ( ) ) Work Phone ( ) Cell Phone or Pager ( ( ) ) Work Phone ( ) School Case Manager: ( ( ) ) Cell Phone or Pager State Zip Work Phone ( ) Date of Birth / /
Cell Phone or Pager
Insurance Information: Company: Medical Clinic/ Physician: Preferred local hospital: (note that staff or EMT/ Paramedic may choose to take you/ your child to the closest location) Personal History: (circle all that apply) *Allergies (Please include any food allergies, latex allergies, bee sting allergies, etc.): Anemia Asthma Cancer Diabetes Ear Emotional Concerns Eye Disease Fainting/ Dizziness Hay Fever Heart Disease Other conditions (please list): Hepatitis Hernia High Blood Pressure Kidney Disease Malaria Migraine Pneumonia Rheumatic Fever Seizures Tuberculosis Policy #: Phone ( ) -
Are you taking any medicine regularly? If yes, please list Do you wear glasses/ contacts?
Comments (include any special medical or personal information you would want an emergency care provider or teacher to know – or special contact information- this would be used in a medical situation but also in the classroom to help with any accommodations or teaching strategies):
Waiver of Liability, Indemnification, and Medical Release
To be signed by the student and parent or other legal guardian (if under age 18 or otherwise have legal guardianship assigned) of each participant in the July 2007 DEEDPTE Manufacturing Camp. READ CAREFULLY BEFORE SIGNING! I have agreed to register (or register my child) to participate in the July 2007 Minnesota Department of Employment and Economic Development-Pathways to Employment (hereafter “DEED-PTE”) Manufacturing Camp, to be held at Hennepin Technical College, Brooklyn Park, MN campus. It is a summer educational enrichment activity program designed to teach young persons with disabilities about the field of manufacturing. I am (or my child is) not required to participate in this program. My (or my child’s) participation in the program is wholly voluntary. The DEED-PTE Manufacturing Camp consists of hands-on summer enrichment program activities in the areas of computer-aided drafting, welding, fluid power and machining. This will include using equipment and materials in the Hennepin Technical College laboratories and going off-site for company tours. I am aware of the dangers and the risks to my (or my child’s) person and property involved in participating in these activities. Risks associated with participation in the DEED-PTE Manufacturing Camp include (but are not limited to) injuries from using equipment and materials in the laboratories, accessing transportation to and from camp as well as to and from company tours, contact with other participants and/or effects of the weather, traffic, and other environmental conditions. All such risks are known and understood by me. In consideration of the DEED-PTE’s agreement to permit me (or my child) to participate in this program, the receipt and sufficiency of which is hereby acknowledged, I agree as follows: 1) I agree (or agree to instruct my child that he or she will be expected) to obey and remain in the presence, custody and control of program personnel, to abide by their instructions and the safety rules and regulations, as set and directed by the DEED-PTE Manufacturing Camp staff (e.g., for proper and safe use of tools/ equipment/ materials as instructed.) Behavior by me (or my child) that, in the opinion of the program staff, results in risk to me (or my child) or other participants or that causes or threatens disruption to the program will disqualify me (or my child) from further participation. I, individually, and on behalf of my heirs, successors, assigns and personal representatives, hereby: a. Release and forever discharge MnSCU, Hennepin Technical College and the State of Minnesota and its employees, agents, officers, trustees and representatives (in their official and individual capacities) (“Releasees”) from any and all liability whatsoever for any and all damages, losses or injuries (including death) I or my child sustain to person or property or both, including but not limited to any claims, demands, actions, causes of action, judgments, damages, expenses and costs, including attorney fees, which arise out of, result from, occur during, or are connected in any -3-
manner with my (or my child’s) participation in the DEED-PTE Manufacturing Camp whether caused by the negligence of the Releasees or otherwise; except that which is the result of gross negligence and/or wanton misconduct by the Releasees. I understand and agree that this waiver covers each and every DEED-PTE Manufacturing Camp activity and event in which I participate (or my child participates). b. Indemnify, defend, and hold harmless MnSCU, Hennepin Technical College and the State of Minnesota Technical and its employees, agents, officers, trustees and representatives (in their official and individual capacities) from any and all liability, loss, damage or expense, including attorney fees, that they or any of them incur or sustain as a result of any claims, demands, actions, causes of action, damages, judgments, costs or expenses, including attorneys fees, which arise out of, occur during, or are in any way connected with my (or my child’s) participation in the DEEDPTE Manufacturing Camp. 3) I hereby consent to allow me (or my child) to receive medical treatment that may be deemed advisable in the event of injury, accident or illness during this activity or event. I hereby acknowledge my obligation to pay for any such reasonably necessary medical treatment that may be provided to me (or my child) by licensed healthcare professionals and facilities. I agree that this Waiver, Release and Indemnification Agreement is to be construed under the laws of the State of Minnesota, U.S.A.; and that if any portion hereof is held invalid, the balance hereof shall, notwithstanding, continue in full legal force and effect. I agree that this Agreement is to be construed broadly to provide a release, indemnification and waiver to the maximum extent permissible under applicable law. In signing this document I hereby acknowledge that I have read this entire document, that I understand its terms, that I am at least eighteen (18) years of age, or that I am the parent or other legal guardian of the Participant named below. I understand that by signing this agreement, I am giving up substantial legal rights of my child’s and/or mine that I/we might otherwise have, and that I have signed this Waiver, Release and Indemnification Agreement knowingly and voluntarily. A photocopy of this form is as valid as the original. 4) Optional: Please Initial here if you agree to allow your (or your child’s) photo to be released to the public:
I agree to have my photo taken and released for promotional purposes of the DEEDPTE Manufacturing Camp only. I also understand that once the information is shared with others, it is no longer protected by this authorization. Participant Initials Parent/ Guardian Initials (if applicable)
Name of DEED-PTE Manufacturing Camp Participant: Date of Birth Signature of Participant: Date Signature of Parent or other legal guardian of participant: (if under age 18 or otherwise have legal guardianship assigned) Date
Other legal notices: Each party will be responsible for its own acts and omissions and the results thereof. The Minnesota Tort Claims Act governs the State of Minnesota (DEED)’s liability under this contract. This contract, and amendments and supplements thereto, shall be governed by and construed in accordance with the laws of the State of Minnesota. Venue for all legal proceeding arising out of this contract, or breach thereof, shall be in the state or federal court with the competent jurisdiction in Ramsey County, Minnesota. This section shall survive termination of this contract. Notice under this contract shall be made in writing. th Notice shall be delivered to: DEED-PTE, Alyssa Klein “or his/her successor”, 1201 89 Ave. NE, Suite 220, Blaine, Minnesota 55434. Upon request, the parties shall provide to each other their relevant policies, procedures, rules, regulations and other materials applicable to the internship. The parties shall inform each other of any pertinent changes in their policies, regulations or other conditions relevant to or applicable to the internship. The parties agree that they will comply with all applicable federal, state and local laws and regulations in connection with their performance under this contract. The parties to this contract are acting as independent contractors. Nothing in this contract is intended to or shall be construed as creating an agency, partnership, joint venture, or representative relationship between the parties. No party shall hold itself out as being an agent, partner or representative of any other party. This contract may be amended, changed or supplemented, provided that any such amendments, changes or supplements are in writing and executed by authorized representatives of all the parties to this contract. This contract may not be assigned without the express written consent of the other parties, but will be binding upon the heirs, administrators, representatives, and successors of the parties. No delay or failure of either party to enforce any provision of this contract will constitute a waiver or limitation of any rights enforceable under this contract. The failure of any party to require performance of any provision of this agreement will in no way affect a party’s right to enforce the same condition at a later date. No waiver by any party of any condition, or of any breach of any term of this contract, in any one or more instances, will be deemed to be or construed as a further continuing waiver of any such term or condition. Each paragraph of this contract is severable from all other paragraphs. In the event any court of competent jurisdiction determines that any paragraph or subparagraph of this contract is invalid or unenforceable for any reason, all remaining paragraphs and subparagraphs will remain in full force and effect. This contract constitutes the complete and entire agreement between the parties as to the nature, terms and conditions of the relationship between them regarding the DEED-PTE Manufacturing Camp and supersedes any and all prior contemporaneous representations or agreements, whether oral or written, between the parties regarding such relationship.