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COMMUNICATION CAMP June 22-26, 2020

PARENT INFORMATION & REGISTRATION DOCUMENTS

Please download this document prior to typing into it.Once downloaded it can be completed electronically and

then printed for ink signatures.

In an effort to save paper, this document has been designed to be printed 2-sided

Please retain all unnumbered pages for your future reference.


Parent’s Checklist & General Info to keep for easy reference(Please keep this page and post it somewhere handy for future reference)

Tuition$450 ($225 deposit by 3/15, balance by 5/15)$400 with Early Bird discount (total due with registration documents by 3/15)

Lunch & Production ViewingFriday, June 26th 1:00-3:00 pm

Contact InformationCamp Director: Jim Alchediak | [email protected] | 919.515.9740Camp Administrator: Laura Kelly | [email protected] | 919.515.9733

Camp Facility AddressButler Communications Services Building 3210 Faucette DriveRaleigh, NC 27695919-513-3045

Additional item not referenced in Registration Pack forms:Headshot picture needed for Student Press Pass: (approx. passport sized, or one that can be cropped)

☐Send digital pic of child for use on Press Pass – [email protected] ☐If no digital pic available, please include picture with the Registration Pack documents

Before mailing the Registration Pack – confirm:☐ Registration Documents only (pages number 1-12)

Tuition Check☐Has “Camp” and Student’s name on the memo line☐Check is signed☐Check is in the envelope

☐Student Press Pass Pic in envelope (if digital not available)

☐Registration Pack Sent (date )


* Tuition Information:

Cost $450: $225 deposit received by March 15th and balance due by May 15th

Early Bird $400 if paid in full when registration is received by March 15thPlease complete ALL pages (11) -- then print, sign where indicated, and mail along with your check to:

NC STATE Dept. of CommunicationAttn: Laura KellyCampus Box 8104Raleigh, NC 27695-8104

Please make checks payable to: NC STATE / Dept. of Communication

Print “CAMP” and student’s name on the memo line

Incomplete forms will not be accepted (e.g., missing pages, and/or forms submitted without deposit

checks)


Office of Finance and Administration Insurance and Risk ManagementEnvironmental Health and Public Safety Campus Box 7521

Environmental Health & Safety CenterIrm.ehps.ncsu.edu Raleigh, NC 27695-7521

P: 919.515.6122

MEMORANDUM

TO: Interested Persons Medical Providers

FROM: Steve OlmsteadDirector of Insurance & Risk Management

DATE: July 1, 2019

SUBJECT: Academic Campers Accident Insurance Program

For general information purposes, an optional Campers Accident Insurance program is available for University Academic Camp participants. The insurance carrier is Consolidated Health Plans, Nationwide Specialty Insurers, and the applicable policy number is: # 50205908817023001.

For Academic Camps, the policy provides coverage for Accidental Medical Expense for day and residential camps only with coverage limits of $25,000 per accident.

The rates for Day camps are $0.30 and for residential camps the rate is $0.51. These are daily rates per participant.

For any administrative questions, please contact Insurance & Risk Management at919-515-1540


Camper Information: Name

Preferred name if different from above

Date of Birth Gender As of Fall 2020, the Camper will be a High School ☐ Junior ☐ SeniorName of High School

Interests (all that apply) ☐ TV Production ☐ Writing ☐ Presentational Speaking

Parent/Guardian Information: Name

Relation to student

Street Address

City State Zip Code

Phone # Email

Emergency Contact Information (Please provide a name other than the one above)

Name

Relation to student

Phone # Email

I, confirm that the person named above has

permission to pick up my child after Camp or respond to an emergency concerning the Camper if I

am unable to be reached. _________________________________________________________

(Parent/Guardian Ink Signature)

C A M P T - S H I R T S are included in the price of tuition. Please indicate your child’s preferred size below. We special-order T-shirts in advance for our campers. These are UNIVERSAL SIZES.

☐ SM ☐ M ☐ L ☐ XL ☐ XXL ☐ XXXL

Page 3 of 11


Safety / Health InformationDo we need to be aware of any health issues affecting the Camper (medical conditions, allergies, sensitivity to bright lights, hearing issues, other special needs)?

Does the Camper have any emotional or behavioral issues that might affect his/her enjoyment at Camp (i.e., fear of public speaking, anxiety within a time-sensitive environment, inability to function in a small enclosed area)?

As the parent/guardian of Camper, , I confirm that my

child will be a junior or senior at High School in fall 2020 and has my permission to attend Communication Summer Camp, June 22-26, 2020 daily from 10 a.m. - 3:00 p.m. on the campus of North Carolina State University in Raleigh, N.C. I have reviewed and signed all documents in this packet as required by NC State University’s Department of Communication for my child to attend COM Camp.

I have enclosed: (please place a check mark on the appropriate line)

☐ An Early Bird tuition check in the amount of $400.00 as in-full tuition

☐ A check in the amount of $225 to reserve my child's space. I will send a check for the balance no later than May 15th. (I understand that if the balance is not received by May 15th, the deposit minus a $25.00 service charge will be refunded to me and my child will lose his/her place in COM Camp.)

☐ It is after March 15th. I have included a check for $450.

I understand that tuition refunds for cancellation, minus a $25.00 service fee, will be given if COM Camp staff are notified by postal mail or email by 5:00 p.m., May 1st. After that date, refunds will be granted only if there is a potential camper on the waiting list who can fill the slot. If there is no student on the waiting list to fill a vacated slot, refunds may be granted at the Director’s discretion.

____________________________________ Printed Name of Parent/Guardian Parent/Guardian Ink Signature

Page 4 of 11


PARENTAL CONSENT / MEDICAL INFORMATION FORMPage 1 of 2

These sheets will be kept on site during Camp hours and will be givento authorities and/or medical team members in the event of an emergency.

Name of Camper: Date of Birth:

Home Address:

City: State: Zip:

Family contact in the event of an emergency (list as applicable):

Father’s Name: Mother’s Name:

Father’s Contact #: Mother’s Contact #:

Guardian’s Name: Guardian’s Contact #:

Alternate contact in case parent(s) or guardian cannot be reached in emergency:

Name:

Relationship: Contact #:

Known allergies (food / drugs / insect bites or stings):

Page 5 of 11


PARENTAL CONSENT / MEDICAL INFORMATION FORMPage 2 of 2

List medical concerns or conditions we should know about: (epilepsy / asthma / diabetes / previous injuries to bones or joints, etc.)

Current medications (list medication / dosage / frequency):

Date of last tetanus booster:

Family Physician: Phone:

Address: State: Zip:

CONSENT FOR TREATMENT and RELEASE OF INFORMATION

I, the undersigned parent/guardian of hereby give permission to the physicians and attendant staff of North Carolina State University Student Health Service, or if it becomes necessary to an off-campus physician or hospital, to perform such diagnostic, therapeutic or surgical procedures as deemed necessary. I authorize camp administrators to sign any form, on my behalf, that acknowledges my responsibility for my child’s medical bills as set out in this agreement, including without limitation the Billing and Acknowledgment form used by North Carolina State University Student Health Services and any billing acknowledgment forms used by a private medical service provider.

I authorize release of my child’s medical information to an outside health professional when a referral is necessary. In addition, I authorize release of medical information to an insurance company, or intermediary for payment of incurred charges.

________________________________________________ Date: Ink Signature of Parent or Guardian

Page 6 of 11


LIABILITY WAIVER, ASSUMPTION OF THE RISK, AND INDEMNIFICATION AGREEMENT FOR THE2020 NORTH CAROLINA STATE UNIVERSITY COMMUNICATION SUMMER CAMP

(Page 1 of 2)

In consideration for being allowed by North Carolina State University and its Department of Communication to participate in the 2019 Communication Camp (hereinafter referred to as “Camp”), the undersigned custodial parent / legal guardian hereby agrees as follows:

I do hereby affirm and acknowledge that my child is participating in the Camp for his/her own personal benefit, and has been fully informed of the inherent hazards and risk to my child associated with Camp activities including property damage; falls; contact with other participants; use of electrical equipment used in a broadcast studio and control room; motor vehicle accidents; sprains; and other personal injuries. I accept and assume responsibility for all risks, known and unknown, regarding my child and their property in the aforementioned activity, and I voluntarily authorize my child’s participation in reliance upon my own judgment and knowledge of my child’s experience and capabilities. I also understand that my child will be covered by accident insurance during his/her time at Camp, the cost thereof included within the Camp tuition fee.

I understand that the determination of my child’s ability to participate in the Camp should be made by my child’s physician if necessary. I understand that I need the approval of a physician if I am uncertain as to his/her physical fitness for the rigors of this Program. I understand that I may be required to seek approval from a physician if there is a health or safety question relative to my child’s condition before being allowed to participate in the Camp, and I have indicated this need on the Camp Registration Packet, Page 2, Box 4. In addition, I give permission to any doctor, hospital, or

other medical facility to release confidentially to the treating physician(s) for my child, any information they may have concerning his/her medical condition, and their professional contact with my child for treatment purposes. I hereby grant my permission for such diagnostic, therapeutic, and operative procedures as deemed necessary for my child.

A photocopy of this permission is to be considered valid as the original. I further understand that treatment for any medical problems my child may suffer is my responsibility and will be paid by me and/or covered by my insurance and the child’s Camp insurance (as limited by the policy).

I shall indemnify and hold harmless North Carolina State University, its trustees, officers, employees, and agents from any liability, losses, costs, damages, claims or causes of action of any kind or nature whatsoever, and expenses, including attorney’s fees, arising from or proximately caused by my child’s participation in Camp, including any travel.

I further agree to accept and assume for myself, my assigns, executors, and heirs any and all such risks and losses that may occur.

I have read the Camp’s Code of Conduct Agreement and hereby accept the regulations of the Camp described therein. I understand that the Camp has the authority to establish and enforce other regulations in addition to these.

Page 7 of 11


LIABILITY WAIVER, ASSUMPTION OF THE RISK, AND INDEMNIFICATION AGREEMENT FOR THE2020 NORTH CAROLINA STATE UNIVERSITY COMMUNICATION SUMMER CAMP

(Page 2 of 2)

I do hereby agree to allow my child to be photographed, and audio- or videotaped by Camp faculty/staff or North Carolina State University. I further agree that my child’s image or likeness in photographs, videos, or audio may be used for educational or promotional purposes, including posting on the Internet. I agree that the use herein may be without compensation to me or my child. I hereby waive any right to inspect or approve the finished electronic, photograph, or printed matter that may be used in conjunction with them now or in the future. I am expressly releasing NC State, its agents, employees, licensees and assigns from any and all claims which I may have for invasion of my child’s privacy, right of publicity, defamation, copyright infringement, or any other causes of action arising out of the use, adaptation, reproduction, distribution, broadcast or exhibition of such recordings.

Please initial only if you DO NOT AGREE to photo/media use, including inclusion in Camp printed or electronic promotional material, on-line, and/or for any public release by North Carolina State University.

I understand that this is a legal document which is binding on me, my heirs and assigns, and on those who may claim by or through me. I am eighteen years of age or older, and have full capacity to enter into this agreement and do so voluntarily.

I HAVE READ THIS AGREEMENT, I UNDERSTAND IT, AND I AGREE TO BE BOUND BY IT.

Printed Name of Parent / Legal Guardian

Ink Signature of Parent / Legal Guardian ________________________________________________

Date:

Page 8 of 11


Code of Conduct Agreement(Page 1 of 2)

In order to provide a safe, fun Camp atmosphere for everyone, we ask Campers - and parents and

legal guardians - to read, sign, and abide by our Code of Conduct Agreement.

I, (Camper’s name) promise to

adhere to the guidelines listed below while attending Communication Summer Camp on the North

Carolina State University campus.

Communication Camp activities centers on work in a broadcast-style television production studio.

Student participants will be instructed on the proper use of cameras, microphones, an audio mixing

console and a video switching console. Attending to instruction on these devices will lead to safe

operation for both students and equipment.

Note that beverages are generally banned from such broadcast facilities. An inadvertent spill can

severely damage or disable electronic equipment. We ask that students adhere to our no food and

drink policy for both studio and master control room. We do allow resealable water containers for

hydration, but insist they be used only as needed and remain away from equipment. Again, spills are

a worst-case scenario, especially on consoles!

A ladder is used in the studio for accessing lighting instruments. Student participants have no need to

climb the ladder as all studio lighting will be preset by instructors. This practice will safeguard against

potential falls as well as electrical lighting hazards.

Student participants are encouraged to wear comfortable clothing, including athletic shoes. Wearing

sandals in the studio is inadvisable as cameras are mounted on broadcast-style pedestal mounts

featuring rolling mechanism. No stubbed toes please!

Page 9 of 11


Code of Conduct Agreement(Page 2 of 2)

★ I understand that violence or bullying of any kind will not be tolerated.

★ I will respect the differences in gender; identity or expression; race/national origin; color; religion; disability; and age of all Campers, faculty, staff, facilitators, and guests.

★ I will respect and obey directions from all faculty, staff, and others in authority while on campus.

★ I will not use foul or abusive language.

★ I will treat all equipment, facilities, and other NC State-owned property as if it is my own.

★ I agree to no drug / alcohol possession or consumption while on campus — including inside vehicles.

★ I agree to no smoking, vaping, or use of tobacco or THC products while on campus.

★ I will turn off all cell phones during Camp sessions or as advised by an NC State facilitator.

★ I will be supportive of my fellow Campers, especially in regards to creative efforts behind and in front of the camera.

Page 10 of 11

I have read, and agree to abide by, these guidelines. I understand that violations of these or other rules set by the NC State University staff could result in suspension or expulsion from Camp without the option of a refund.

Camper’s Ink Signature

Parent / Guardian Ink Signature

Date

__________________________________________________________________


Camper Transportation to and from Camp(page 1 of 2)

In order to provide a safe drop-off and pick-up routine, we need to know how your child will arrive and

depart the NC State campus each day. Campers should arrive by 9:50 a.m. each morning; Camp

dismisses daily at 3:00 p.m. We have implemented a check-in/check-out protocol at the Butler

Communications Building entrance to ensure that we know that each camper has arrived and

departed. A map of the Camp location and drop off area is included in this packet. If your camper is

not picked up by 3:15 p.m., s/he may be taken by staff to Winston Hall - Room 201, and Driver will be

responsible to pick up camper there. Winston Hall is at 2301 Hillsborough St.

Camper’s Name (please print)

Method of arrival and departure: My child will be:

☐Dropped off and picked up by a parent or guardian each day.

☐Driving his/her own vehicle to and from Camp and will need an NC State temporary parking permit

☐Biking to and from Camp. I understand there is a great deal of traffic on campus and surrounding the Western Blvd. area that could be dangerous for my child.

☐Riding with who is also attending COM Camp

☐ Riding with another camper who is driving. Name:

☐Riding the city bus or Wolfline to get to and from Camp.

Page 11 of 11


Camper Transportation to and from Camp(page 2 of 2)

My child is aware of how they will arrive and depart from the Camp location and with whom.

Parent/Guardian Ink Signature

_____________________________________________________________

Date

Comments (optional)

Page 12 of 11

Exception:

I do not authorize at the close of any Camp day, or at any time.

(Note that each day we will check drivers’ photo ID’s of anyone who arrives to pick up your child.)


Final Day Info & RSVP

Throughout the week, students will work on two 10-minute newscasts. The final productions will be shown to parents/family/friends on the last day of camp. Lunch will be provided.

Due to space limitations, each student may invite only 2 guests to attend. Each family will receive one parking permit for the event - paid for by COM Camp. If additional permits are needed, please contact the Camp Administrator, Laura Kelly. Additional permits can be purchased at a cost of $10.00 each.

Students arrive at the regular 10:00 am camp start time, guests are invited to join us later.

Presentation Day Guest Details June 26, 2020 1:00 - 3:00

RSVP:

Student Name:

# of Guests Attending (do not include student):

Email address to send Parking Permit

Extreme food allergies? Additional Comments?

Page 13 of 11


If you wish to drop off your Registration Packet and check, find your way to Winston Hall @ 2301 Hillsborough Street (right across from Bruegger’s Bagels). Enter the building and turn right and walk down the hall to get to the stair well - it will be on your left. Go up the stairs and at the top, enter onto the 2nd floor hallway.

The Communication Department Administrative Suite will be on your left in Winston 201. You may leave your packet with the Receptionist.


Map to COM Camp facility

NOTE:Faucette Drive is a small service road that runs parallel to Western Blvd. and BEHIND the entrance to Butler Communications Services Building.

When approaching from Western Boulevard (recommended vs. taking Hillsborough Street), drive past the Faucette Drive intersection and continue on to the next road on your right, and turn right. The Butler Bldg. is on the corner.


Students with parking passes have been assigned to park in the WEST DECK. West Deck is on the left when you turn right in front of the Butler Bldg. — directly across from the building. Students will have an easy, traffic- free walk from the deck to the building.