Albany State Youth Enrichment Program (ASYEP):Camper Application

Albany State Youth Enrichment Program (ASYEP):

Camper Application

The Albany State Youth Enrichment Program (ASYEP) Summer Camp is a free, seven( 7) week summer camp, sponsored by Albany State University & the ASU Department of Athletics. The program’s mission “Is to provide youth with a safe and nurturing environment where they can be active, learn new skills, build self-confidence, and have fun over the summer”. It is offered to both boys and girls (7-14) who are seven on or before May 1, 2025.

CAMP DATES: Monday, June 2, 2024 – Friday, July 18, 2024

DAILY CAMP TIMES: 7:30 a.m. to 3:30 p.m.

AGE REQUIRMENT: 7 – 14 years old

Please Note:

• We will NOT accept any mailed, emailed, or faxed copies of the application or medical form.

• We do NOT accept requests for specific group assignments or pairings with another camper.

All youth participating in ASYEP will receive the following:

• Sports and Education Activities led by quality youth development professional, including a Career Day

• Daily breakfast and lunch

• ASYEP T-shirt

• Camp Awards

During the 2024 ASYEP, all youth will participate in the following Enrichment and Sports programs:

• Basketball • Swimming • Science

• Football • Tennis • English

• Personal Health • Volleyball • Technology

• Soccer • Mathematics

• Kickball

Youth Participant Information

Participant Last Name:*

Participant First Name:*

Age:*

Gender:*

Date of Birth:*

Address:*

City:*

State:*

Select

Zip Code:*

Name of School Attended:*

Last Grade Completed in School:*

Parent(s) / Guardian(s) Information

Parent/Guardian Last Name:*

Parent/Guardian First Name:*

Is your address is same as child’s address above?*

Yes

Parent / Guardian Address:

(Address, City, State & Zip Code)

Home Phone:*

Phone

Cell Phone:*

Phone

Work Phone:*

Phone

Email Address:*

Notice of Exemption

I, (Parent / Guardian), acknowledge that I have been informed this program is not a licensed child care facility. I also understand this program is not required to be licensed by the Georgia Department of Early Care and Learning and this program is exempt from state licensure.

Parent/Guardian: Please check the box to indicate that you have read, understood and agree to the terms for the Notice of Exemption above:*

Notice of Exemption So Agreed This Date:*

Emergency Contact Information

Someone other than parent/guardian above.

Person to notify in case of emergency:*

First and Last

Relationship:*

Primary Contact’s Phone Number:*

Phone

Primary Contact Cell Phone:*

Phone

Address - Emergency Contact:*

City - Emergency Contact:*

State - Emergency Contact:*

Select

Zip Code - Emergency Contact:*

Secondary Contact’s Name:*

Secondary Contact Phone Number:*

Phone

Medical Information

Please attach additional details as necessary.

Family Physician:*

Family Physician Phone Number:*

Phone

Insurance Provider:*

Insurance Provider Phone Number:*

Phone

Policy Number:*

Insurance Card / Other Medical Documents*

NOTE: The institution does not offer any form of health, liability, or other types of insurance for participants.

Please attach a copy of the front and back of your insurance card with this form.

You may also attach any additional medical forms as needed.

Drag and drop files here or

Authorization for Medical Care

I understand that my child is voluntarily participating in an Albany State University Program. By signing this form I hereby acknowledge that all information is accurate and current, that any activity restrictions, allergies, and medications are listed on this form, and to the best of my knowledge, my child is capable of participating safely in the program. I acknowledge that my failure to disclose relevant information may result in harm to my child and/or others during this program. I agree to notify the program of any changes in my child’s mental, physical or medical condition before the program begins.

I understand that Albany State University does NOT provide medical insurance for my child and that I should consult my child’s physician before allowing my child to participate in this program. In the case of accident or illness, I hereby authorize the program staff to administer or seek medical treatment for my child, as they see fit, including routine first aid care or emergency medical treatment. I hold harmless and agree to indemnify the program, Albany State University, and the Board of Regents from any claims, causes of action, damages, and/or liabilities arising out of or result from said medical treatment. I acknowledge that I am solely responsible for any hospital or other costs arising out of any bodily injury or property damage sustained through my child’s participation in such voluntary program.

Parent/Guardian: Please check the box to indicate that you have read, understood and agree to the terms for Authorization for Medical Care above:*

Authorization for Medical Care So Agreed This Date:*

2025 PARTICIPANT QUESTIONARE

Previous ASYEP Participant:*

Yes

If yes, please select the years of participation:

Select

Other (Please specify here):

ASYEP partners with a number of community agencies to support our programming. Please indicate below which community programs your child participates in as this helps us better understand how our youth are being served in the community. (Please check all that apply.)*

My family receives housing services from the (Albany Housing Authority)

My family receives SNAP (Supplemental Nutrition Assistance Program) benefits.

No, my family does not receive housing services or SNAP.

Are you an immigrant/refugee?*

Yes

Client Refused

If yes, write in client’s country of birth:

Family’s Annual Household Size:*

List # of individuals living in household

Is your child eligible for the free/reduced lunch program?*

Yes

Unknown

Client refused

Is your child enrolled in the Medicaid program?*

Yes

Does your child have one physician that he or she goes to for all health matters?*

Yes

No, and we would like information about finding one

No, but we do not need any information about this

Does your child have any dietary restrictions?*

Yes, my child has the following food allergies:

Yes, my child is a vegetarian.

No dietary restrictions.

Food Allergies:

RELEASE, WAIVER OF LIABILITY, AND COVENANT NOT TO SUE

(READ CAREFULLY BEFORE SIGNING)

The undersigned hereby acknowledges that participation in collegiate athletic programs and recreational activities involve an inherent risk of physical injury and assumes all such risks. The undersigned hereby agrees that for the sole consideration of Albany State University (the Institution) allowing the undersigned to participate in voluntary recreational programs or collegiate athletic activities and, in connection therewith, making available to the undersigned for his/her use while participating in such programs or activities, certain equipment, facilities, grounds, or personnel of the institution, the undersigned participant does hereby waive liability, release forever discharge the Institution and the Board of Regents of the University System of Georgia (the Board of Regents), its members individually, and its officers, agents and employees of and from any and all claims, demands, rights and causes of action of whatever kind or nature, arising out of all known and unknown, foreseen and unforeseen bodily and personal injuries, damage to property, and the consequences thereof, including death, resulting from my voluntary participation in or in any way connected with such recreational programs and collegiate athletic activities. He/she will not sue the Institution, the Board of Regents, its members individually, its officers, agents or employees for any claim for damages arising or growing out of his/her voluntary participation in recreational programs or collegiate athletic activities. The undersigned understands that the acceptance of this release, waiver of liability and covenant not to sue the Institution or the Board of Regents or any agent or employee thereof, shall not constitute a waiver, in whole or in part, of sovereign or official immunity by said Board; its members, officers, agents, and employees.

In signing this release, the undersigned acknowledges and represents that he/she has read the foregoing waiver, release and covenant not to sue, understands it, and has signed it voluntarily of his/her own free act and deed. He/she further acknowledges that no oral representation, statements or inducements, apart from the foregoing written agreement, have been made and that he/she is at least eighteen (18) years of age and fully competent. If he/she is under the age of eighteen (18), a parent shall sign as his/her legal representative, accepting fully each and every covenant, release, discharge and waiver of liability contained herein. The undersigned fully executes this Release for full, adequate and complete consideration, fully intending to be bound by same. The undersigned understands that he/she is required to provide his/her own Accident and Medical Insurance. The undersigned hereby agrees that he/she is financially responsible for all such accident and medical expenses that he/she may incur as a result of his/her participation in the program or activity. Accident and Medical insurance is not provided by the Institution or the Board of Regents. The undersigned understands that any injury sustained while voluntarily participating in Albany State University collegiate and recreational programs/activities will not be covered by the school’s secondary insurance policy. The undersigned understands that while participating in the program or activity sanctioned by the Institution and/or Board of Regents, he/she is subject to the Institution’s and/or Board of Regents’ regulations, guidelines and procedures, the laws of the United States and the laws and regulations of the State of Georgia. The undersigned understands that in the event he/she violates any of these rules or regulations or becomes disruptive such that he/she is a threat to other participants, the designated agent of the Institution and/or Board of Regents shall have the right to dismiss him/her from the program or activity.

Further, the undersigned understands that this release, waiver or liability and covenant not to sue shall be effective for semester or the activity as indicated above and occurring from 6/2/2025 to 7/18/2025.

NOTE: YOU WILL BE REQUIRED TO SIGN AND DATE A PHYSICAL COPY OF THE FORM FOR OUR RECORDS UPON ARRIVAL.

Parent/Guardian: Please check the box to indicate that you have read and understood the Release/Waiver/Covenant above:*

Release, Waiver of Liability, and Covenant Not to Sue So Agreed This Date:*

WAIVER of LIABILITY/RELEASE for use of facilities for RECREATIONAL and/or WATER-BASED ACTIVITIES

I hereby acknowledge that participation in recreational and/or water-based activities involves an inherent risk of physical injury, property damage, and other dangers, including, but not limited to, hypothermia, broken bones, strains, sprains, bruises, concussions and drowning. I hereby acknowledge that I have voluntarily chosen to use the recreational facilities of Albany State University from 6/2/2025 to 7/18/2025. I understand that by providing said facilities, Albany State University does not accept and expressly disavows any responsibility for overseeing or monitoring any activities in which participant voluntarily engages while on its campus. If swimming and water-related activities are involved, I hereby agree to secure the services of a lifeguard, certified by the Red Cross, who will be on duty during the entire time that participants are permitted use of said facilities. I voluntarily accept total responsibility for engaging in the foregoing activities for which I have the prerequisite skills, qualifications, preparation, training and experience. In consideration for the use of said facilities, I hereby release, waive, discharge, and covenant not to sue, the Board of Regents of the University System of Georgia (hereafter SOR) and Albany State University (hereafter ASU), theirs officers, servants, agents and employees from any and all liability, claims, demands, actions and causes of action whatsoever arising out of or relating to any loss, damage or injury, including death, that may be sustained by me, or to any property belonging to me, whether caused by the negligence of ASU and/or BOR, or otherwise, while using said facilities and participating in the said activities, while in transit to or from the premises, or in any place or places connected with the activity.

I understand that I am required to provide my own Accident and Medical Insurance. I hereby agree that I am financially responsible for all such accident and medical expenses that I may incur as a result of my participation in said activities. Accident and Medical insurance is not provided by ASU or BOR.

I understand that while present on the campus of ASU and/or BOR, I am subject to ASU and BOR regulations, guidelines and procedures, the laws of the United States and the laws and regulations of the State of Georgia. I hereby further agree that this release shall be construed in accordance with the laws of the State of Georgia.

I further acknowledge that no oral representation, statements or inducements, apart from the foregoing written agreement, have been made and that I am at least eighteen (18) years of age and fully competent. If I am under the age of eighteen (18), a parent shall sign as my legal representative, accepting fully each and every covenant, release, discharge and waiver of liability contained herein. I execute this Release for full, adequate and complete consideration, fully intending to be bound by same.

NOTE: YOU WILL BE REQUIRED TO SIGN AND DATE A PHYSICAL COPY OF THE FORM FOR OUR RECORDS UPON ARRIVAL.

Parent/Guardian: Please check the box to indicate that you understand and accept the Authorization for Medical Care above:*

WAIVER of LIABILITY/RELEASE for use of facilities for RECREATIONAL and/or WATER-BASED ACTIVITIES So Agreed This Date::*

Authorized Pick Up

*Please note that only the enrolling parent will be permitted to complete this form.

Please list any individual who is authorized to pick up your child, including yourself. Each authorized person must be at least 16 years of age. The above-named child will not be permitted to leave the program with anyone who is not listed below. Authorized individuals must pick up the child in person and may be requested to show identification to program staff. Children will not be released to persons who fail to provide acceptable identification upon request.

I authorize the following responsible persons to pick up my child from the program (attach additional pages as needed):

First Authorized Person:*

First, Last Name

First Authorized Person Phone Number:*

Phone

First Authorized Person Relationship to Child:*

Second Authorized Person:

First, Last Name

Second Authorized Person Phone Number:

Phone

Second Authorized Person Relationship to Child:

Third Authorized Person:

First, Last Name

Third Authorized Person Phone Number:

Phone

Third Authorized Person Relationship to Child:

Fourth Authorized Person:

First, Last Name

Fourth Authorized Person Phone Number:

Phone

Fourth Authorized Person Relationship to Child:

Please note that children must be picked up by designated times. If an authorized adult is unable to be reached, program members will contact the local police department as a last resort to take your child home. If you are not at home, your child will be released to the Division of Family and Children Services.

Authorized Dismissal

My child is at least 16 years of age and will be responsible for his/her own transportation to and from the Program. My child may sign himself/herself out at the end of the program activities.

Parent/Guardian: Please check the box to indicate that you have read, understood and agree to the terms for Authorized Dismissal above:*

Authorized Dismissal So Agreed This Date:*

ALBANY STATE UNIVERSITY YOUTH PROGRAMS PARTICIPANT CODE OF CONDUCT

The Program has established rules and standards of conduct for all Participants. It is the responsibility of the Parent/Legal Guardian and the Participant to review the Program rules and standards of conduct. Dismissed Participants are not eligible for a refund of any fees or expenses. The Parent/Legal Guardian is responsible for all costs associated with removing the Participant from the Program due to his/her misconduct, including but not limited to transportation costs to return the Participant home.

PARTICIPANT AGREEMENT

I understand that as a condition for participating in the Program I must comply with the Program’s rules and standards of conduct and follow all reasonable direction of the Program Staff. Failure to comply with the Program’s rules and standards of conduct or failure to comply with the reasonable direction of Program Staff may result in my being dismissed from the program.

PARENT/LEGAL GUARDIAN AGREEMENT

I understand that my child will be subject to the rules and standards of conduct of the Program and the University System of Georgia. I further understand that my child’s violation of the rules and standards of conduct or failure to comply with the reasonable direction of Program Staff may result in my child’s dismissal from the Program. I accept responsibility for all costs associated with removing my child from the Program, including but not limited to transportation costs to return the Participant home. I understand that Dismissed Participants are not eligible for a refund of any fees or expenses.

NOTE: YOU WILL BE REQUIRED TO SIGN AND DATE A PHYSICAL COPY OF THE FORM FOR OUR RECORDS UPON ARRIVAL.

Please check the box to indicate that you understand and accept the agreement above:*

Participant Code of Conduct So Agreed This Date:*

Albany State University Youth Programs for Minors Media, Photo and Video Release Form

Please read the following release carefully, then please check the box.

YES

I give permission for my child’s name, likeness, image or voice to be used in photographic, Video, digital, or other recording forms. I give my permission for the program to use those recordings or works produced by my child (e.g., artwork) for promotional, commercial, information and educational purposes in any and all media (including the internet) now existing or hereafter devised, for any purpose whatsoever, as deemed appropriate by Albany State University (ASU). This consent includes the unrestricted right and permission to copyright and use, reuse, publish, republish, edit, alter, and exhibit and/or distribute any images of my child or in which my child may be included intact or in part, composite or distorted in character or form, without restriction as to changes or transformations. I understand that the image may be readily accessible by the general public. I further acknowledge and agree that ASU and the Board of Regents of the University System of Georgia, its members, officers, agents, and employees shall not be responsible for any use of the image by any third party accessing the image through the internet or any other manner. I understand that I will not have an opportunity to review or approve uses of the recording or works, and I hereby waive any right to inspect or approve the same. I understand that neither my child nor I will receive payment or any other compensation for the taking or use of any recordings or works created as a result of my child’s participating in the program. To the extent the image or media of my child is an educational record and may contain personally identifiable information about my child as defined by the Family Educational Rights and Privacy Act of 1974 (“FERPA”), I hereby consent to the release of the image or media. I understand that I have the right not to consent to my child being videotaped, photographed, or recorded during the program, and the right not to consent to the release or use of the image or media and any personally identifiable information about my child contained in the media, and that this consent shall remain in effect until revoked by me in writing and delivered to ASU, though any such revocation shall not affect disclosures previously made p0rior to its receipt. I further release, discharge, indemnify, and hold harmless Albany State University and the Board of Regents, its members, officers, agents, and employees from and again all liability, actions, debits, claims, demands, rights, injuries, damages, or causes of action of every kind whatsoever, arising from and by reason of any known or unknown, foreseen and unforeseen, relating to the taking or use of the recordings or works of my child, including, without limitation, any and all claims for invasion of privacy, rights or publicity, libel, and slander. I understand that the acceptance of this release and waiver of liability by ASU and the Board of Regents of the University System of Georgia shall not constitute a waiver, in whole or in part, of sovereign immunity by the Board, its members, officers, agents, and employees. This authorization and release shall inure to the benefit of the heirs, legal representatives, licensees, and assigns of ASU, and the Board of Regents. If any provision of this Media, Photo and Video Release shall be held invalid or unenforceable, such provision will be deemed severable without affecting the validity or enforceability of the remaining provisions.

YES

NO

I do not grant permission for my child’s name, likeness, image or voice to be used in any form, unless necessary for the administration of the program while my child is participating.

I hereby certify that I am over 18 years of age, suffering under no legal disabilities, that I have read the above carefully before signing, and fully understand its contents. This release shall be binding upon me, my heirs, legal representatives, and assigns.

Media, Photo, and Video Release*

Media, Photo and Video Release So Agreed This Date:*

Personal Identifiable Information (PII) Notice:

All personal data and special categories of sensitive personal data collected or processed by Albany State University (ASU) must comply with the ASU Cybersecurity Program Plan, as authorized by the Board of Regents Policy Manual Section 10.4 Cybersecurity:

https://www.usg.edu/policies

Anyone suspecting his or her sensitive personal data has been exposed to unauthorized access, report your suspicion to:

LegalAffairs@asurams.edu

Otherwise, questions concerning GDPR can be forwarded to LegalAffairs@asurams.edu. Typing your name in the box below and submission of this application provides consent to and acknowledgment of the ASU Data Security and Privacy Policy.

Please check the box below to indicate that you have read and understood the PII policy above.

Personal Identifiable Information (PII) Consent:*

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