Non-Residential Application
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2018 AGTECH CENTURY 21
Summer Enrichment Program
Non-Residential Application
Sponsored by
US Department of Agriculture/National Institute of Food and Agriculture
And Florida A&M University/College of Agriculture and Food Sciences/Cooperative Extension Programs
Contact Information
Florida A&M University
Cooperative Extension Program
1740 S. Martin Luther King, Jr. Blvd.
215 Perry Paige Bldg., South
Tallahassee, FL 32307
Phone: (850) 599-3546
Fax: (850) 561-2151
Extension Personnel
Dr. Glen Wright, Director of Veterinarian/Animal Health – glen.wright@famu.edu
Dr. Carmen Lyttle-Nguessan, Research Associate - Email: carmen.lyttlenguessa@famu.eduFAMU IS AN EQUAL OPPORTUNITY/EQUAL ACCESS UNIVERSITY
WHAT IS AGTECH CENTURY 21?
• AgTech Century 21 is a local summer enrichment program designed to help middle to
high school students learn about careers in agricultural sciences.
• AgTech Century 21 is designed to serve local group underrepresented/underserved by
other similar programs (e.g. Ag-Discovery). The program admits students 13-17 years old
to learn about careers in agriculture, animal science and related fields. Students will also
participate in character-team building activities, and diversity workshops to promote
learning and personal growth development. Students admitted to the program will
commute to, and not reside on, the campus of Florida A&M University (FAMU) in
Tallahassee, Florida.
• AgTech Century 21 is unique opportunity to learn about the anatomy and physiology of
animals. It is designed to enhance student’s knowledge and background in science, and
stimulate and create interest in animal science and related fields.
WHO SPONSORS AGTECH CENTURY 21?
AgTech Century 21 is funded by USDA/NIFA (National Institute of Food and Agriculture) and is
coordinated by the FAMU Cooperative Extension Program, a component of the FAMU College of
Agriculture and Food Sciences (CAFS).
HOW MUCH WILL IT COST?
The cost is free for students selected to participate in the 2018 AgTech Century 21 program.
WHEN WILL THE PROGRAM TAKE PLACE?
(Orientation 7/15/2018) Regular Session: 07/16/2018 through 07/20/2018
Note: Only 20 students will be selected to participate.
WHAT ARE THE CRITERIA TO PARTICIPATE?
•Participants must be local residents of Tallahassee, Quincy and surrounding areas
•Daily commute to the campus – transportation must be provided by parents.
•Must be enrolled in middle or high school as student in good-standing (Must have a minimum of
2.0 GPA on a 4 point scale).
• Must have genuine interest in agriculture/animal sciences
• Must be able to attend entire program of activities
• Must be respectful of the rules of the summer program
HOW DO I APPLY?
• The eligible ages for AgTech Century 21 are 13 through 17 (You must be at least the minimum
eligible age and no older than the maximum eligible age as of June 30, 2018)
• You must submit a complete package to FAMU/CEP post-marked no later than June 18, 2018.
FAMU/CEP will not accept application packages that are post-marked after those date, or
incomplete.
• Here is what to put in your application package:
o Three character references-letters from people not related to you who know you well. At least one
of the three references must come from a recent teacher or counselor
o A completed application form.
o Please include a two page essay written by the student entitled “Why I Want To Attend the
AgTech Program at Florida A&M University, and What I Want To Learn.” In the essay, include
information on your interests and hobbies and explain what you want to do when you grow up. Be
sure to include your full name, age, home address, home telephone number, and email address.
FAMU IS AN EQUAL OPPORTUNITY/EQUAL ACCESS UNIVERSITYo Only Students who have not attended the program will be accepted.
FORMS! FORMS! FORM!
VERY IMPORTANT!!!
PLEASE COMPLETE ALL FORMS AND RETURN TO:
Carmen Lyttle-N’guessan, Ph.D.
AgTech Century 21
College of Agriculture and Food Sciences (CAFS)
Cooperative Extension program (CEP)
Florida A&M University (FAMU)
1740 S. Martin Luther King, Jr. Blvd.
215 Perry Paige Bldg. South
Tallahassee, FL 32307
Please include Proof of School Enrollment (Report card, Transcript, or Letter from the School)
FAMU IS AN EQUAL OPPORTUNITY/EQUAL ACCESS UNIVERSITYAGTECH CENTURY 21
Telephone: (850) 561-2931
PARTICIPANT LIABILITY RELEASE Fax: (850) 561-5346
By signing this MEDICAL CONSENT and LIABILITY RELEASE, I assume any and all liability for any
accident, injury, damages or loss that may occur during participation or as a result of Summer Camp
Activities at Florida A&M University.
In consideration for the acceptance into or voluntary participation in the above stated activity/event, I/We
hereby release, waive and discharge any and all demands and claims for, but not limited to, damages,
personal injury, property damage, illness, death or loss which I may have or which hereafter accrue to me,
against FAMU due to participation in or as a result of the above mentioned activity/event. This release
will discharge and hold FAMU harmless from and against any and all liability demands (including
attorney fees and court cost) arising out of or connected in any way with participation in or as a result of
the above mentioned activity/event, even though that liability may arise out of negligence on the part of
persons or agencies mentioned above.
I/We further understand that damages, accidents, injuries or death could arise out of participation or as a
result of the above mentioned activity/event. Knowing this, I hereby agree to assume those risks and to
release and hold all agencies and persons mentioned above harmless who (through negligence or
carelessness) might otherwise be liable to me.
I/We fully understand and agree this disclaimer, release, waiver and assumption of risk, is to be binding
on my heirs and assigns.
I HAVE READ THIS ENTIRE RELEASE. I FULLY UNDERSTAND IT AND AGREE TO BE
LEGALLY BOUND BY IT.
_______________________________________________
Print Name of Minor or Participant (if under 18 years old)
Minor’s Date of Birth_________________________________________
Print Name of Parent, Legal Guardian or Custodian ____________________________________
Print Name of Participant (if 18 years or older)________________________________________
Signature of Parent, Legal Guardian or Custodian Date___________________________
_______________________________________
Signature of Participant (if 18 years or older) Date___________________________
_______________________________________
Address______________________________________________________________________
Phone Number _____________________ Email ___________________________________
FAMU IS AN EQUAL OPPORTUNITY/EQUAL ACCESS UNIVERSITYENVIRONMENTAL HEALTH AND SAFETY
TELEPHONE: (850) 599-3442
FAX: (850) 561-8042
DOMESTIC Travel Participation Agreement
(Non-FAMU Students and Staff)
This is a legal and binding agreement which, when signed, will permanently limit your
ability to recover from the parties indicated below for injuries or losses you may sustain as
a result of participation in off-campus activities.
References to Florida A&M University (henceforth referred to as FAMU) include Florida A&M
University, acting by and through its Board of Trustees, the Florida Board of Governors, the
State of Florida, its agents, officers, faculty and employees.
PARTICIPATION AGREEMENT
I, ____________________________________freely choose and/or volunteer to participate in the
(Print Name)
trip to ____________________________on or about ________________ to _________________
(henceforth referred to as The Trip).
I fully understand that FAMU in no way represents, is not an agent of, and has no responsibility
for, any third party, including without limitation any sponsor that may provide any services
including food, lodging, travel, or any services associated with The Trip. I agree to inform
myself about the potential dangers of the areas I am traveling to and precautions which should be
taken.
I have advised FAMU that there is no health or psychological conditions that preclude my
participation in The Trip. I agree to make personal decisions and conduct my private life in an
intelligent, prudent fashion, paying particular attention to local conditions. I agree to assume
responsibility for the consequences of my own decisions and actions.
I understand that should I have or develop legal problems with any U.S., foreign nationals or
government or other person/entity, I will attend to the matter personally with my own personal
funds. I understand that FAMU is not responsible for providing any assistance under such
circumstances and FAMU will not act as my legal representative if I am detained or arrested.
I agree that participating in any activity is an acceptance of risk of injury or death and
property loss or damage.
FAMU IS AN EQUAL OPPORTUNITY/EQUAL ACCESS UNIVERSITYI agree that my safety is primarily dependent upon my taking proper care of myself. I
understand that it is my responsibility to know what I will need for The Trip and to
provide what I will need. I agree to make sure that I know how to safely participate in
any activities, and I agree to observe any rules and practices which may be employed to
minimize the risk of harm. I am also aware that there is certain behavior that is
unacceptable and could lead to possible disruption of my participation in The Trip. I
assure FAMU that I shall act in an appropriate manner at all times. Such behavior shall
include times when in the company of other participants on The Trip and when I may be
physically separated from the participants on The Trip.
I will not wear, use or do anything that would pose a hazard to myself or others, including using
or ingesting any substance which could pose a hazard to myself or others. I agree that if I do not
act in accordance with this agreement I may not be permitted to continue to participate in The
Trip.
Initial _______ CONTINUE WITH THE NEXT SECTION
INFORMED CONSENT AGREEMENT
I understand that despite precautions taken, accidents and injuries may occur. I also understand
that travel and other activities undertaken during The Trip may be potentially dangerous and that
I may be injured and/or lose or damage personal property as a result of my participation.
Therefore, I ASSUME ALL RISKS RELATED TO THE ACTIVITIES including but not
limited to:
• Death, injury or illness from accidents of any nature whatsoever, including but to
limited to bodily injury of any nature whether severe or not which may occur as a
result of participating in an activity or contact physical surroundings or other
persons; arising from travel by air, car, boat, bus, train or any other means.
• Death, injury or illness including food poisoning arising from the provision of
food or beverage by restaurants or other service providers.
• Loss or injury as a result of a crime or criminal act, terrorism, war, civil unrest,
riot, detention by a foreign government, arrest or other act of any government or
authority.
• Theft of or loss of my personal property while in transit or during The Trip.
• Natural disaster, weather, strikes, wars, hostilities or other disturbances, and
alteration or cancellation of The Trip due to such causes.
I acknowledge and agree to accept all responsibility for loss or additional expenses due to delays
or other changes in the means of transportation, other services, sickness or injury, weather,
strikes, or other unforeseen causes. I acknowledge and understand that FAMU assumes no
liability whatsoever for any loss, damage, destruction, theft or the like to Participant’s luggage or
personal belongings, and that Participant has retained adequate insurance or has sufficient funds
to replace such belongings and will hold FAMU harmless therefrom.
FAMU IS AN EQUAL OPPORTUNITY/EQUAL ACCESS UNIVERSITYI also acknowledge and understand that in the event I become detached from The Trip group, fail
to meet a departure bus, airplane, or train, or become sick or injured, I will bear all responsibility
to seek out, contact, and reach The Trip group at its next available destination, and that I shall
bear all cost attendant to seek out, contact and reach The Trip group at its next available
destination.
I further acknowledge that the aforementioned is not inclusive of all possible risks associated with
The Trip and in no way limits the extent or reach of this release and covenant not to sue. I further
understand that participating in The Trip is an acceptance of risk of injury or death and property
loss or damage.
Initial _______ CONTINUE WITH THE NEXT SECTION
MEDICAL CONSENT AND LIABILITY RELEASE
I understand and agree that FAMU does not have medical personnel available at the location of
The Trip, during transportation, or anywhere in a foreign country.
I hereby grant permission for emergency medical service to be rendered as deemed necessary. I
do hereby voluntarily consent and authorize FAMU, in the event of an accident, illness or injury
to take whatever measures and actions considered necessary and warranted under the
circumstances to protect, safeguard and minimize further injury to my health and safety. I
understand that such actions may involve or require placement in a hospital or another medical
facility for services and treatment. For these expenses I accept total responsibility. Any
transportation expenses by any mode will be a debt and liability for which I accept total
responsibility.
I hereby further declare, represent and agree, that in the event that FAMU has to exercise the
above voluntarily given medical authorization and consent, that I hold harmless, release and
forever discharge FAMU from any and all liability, damages, claims and demands whatsoever,
including attorneys fees and court cost, which I or any heir or assigned will make. I am aware of
aware of my personal needs and hereby assure the University that I have consulted with a medical
doctor, as I may have deemed necessary, with regard to any personal needs. Further, I am aware
that the University cannot be responsible for attending to any medication needs of the
undersigned.
Initial _______ CONTINUE WITH THE NEXT SECTION
FAMU’S RIGHTS AND POWERS
FAMU reserves the right and power to cancel without penalty the offering and conduct of The
Trip and to withdraw any part of The Trip and to make any alterations, deletions, or modifications
in the itinerary and /or The Trip as deemed necessary by FAMU.
Initial _______ CONTINUE WITH THE NEXT SECTION
FAMU IS AN EQUAL OPPORTUNITY/EQUAL ACCESS UNIVERSITYRELEASE FROM LIABILITY, INDEMNIFICATION AGREEMENT AND COVENANT NOT TO SUE
Knowing the dangers, hazards, and risks of such activities, and in consideration of being
permitted to participate in The Trip, I agree, to the fullest extent permitted by law, to FOREVER
RELEASE and on behalf of myself, my spouse, heirs, representatives, executors, administrators
and assigns, HEREBY DO FOREVER RELEASE FAMU from any cause of action, claims, or
demands of any nature whatsoever, including but not limited to a claim of negligence which I or
my spouse, heirs, representatives, executors, administrators and assigns may now have, or have in
the future against FAMU on the account of personal injury, bodily injury, property damage,
death, accident or loss of any kind, arising out of or in any way related to my participation in The
Trip and/or the use of facilities, equipment, or services in association with The Trip howsoever
the injury or loss is caused, whether by the negligence of FAMU or otherwise.
Knowing the dangers, hazards, and risks of such activities, and in consideration of being
permitted to participate in The Trip, I COVENANT NOT TO SUE and agree to INDEMNIFY AND
HOLD HARMLESS FAMU from any and all causes of action, claims, demands, losses or costs of
any nature whatsoever arising out of or in any way relating to my participation in The Trip and
my use of facilities, equipment, or services in connection with The Trip. I hereby certify that I
have full knowledge of the nature and extent of the risks inherent in The Trip and the use of
facilities, equipment, or services in association with The Trip, and that I am voluntarily assuming
all risks, whether known or unknown.
I understand that I will be solely responsible for any loss or damage, including death, which I
sustain or cause, whether in whole or in part, while participating in The Trip and my use of
facilities, equipment, or services in association with The Trip, and that by this agreement I am
relieving FAMU of any and all liability for such loss, damage or death.
My signature indicates that I have read, understood, and freely signed this agreement. I further
certify that I am at least eighteen (18) years of age and that I am otherwise legally competent to
sign this agreement. I further understand that the terms of this agreement are legally binding and I
certify that I am signing this agreement after having carefully read and understood the same, of
my own free will and fully intending to be legally bound by the same. This agreement is made in
full, adequate and complete consideration of my participation in The Trip.
This agreement shall be construed and enforced in accordance with the laws of the State of
Florida, and I consent to the jurisdiction of said state. I expressly agree that this waiver and
release is intended to be as broad and inclusive as permitted under the laws of the State of
Florida, that if any portion hereof is held invalid, it is agreed that the balance shall,
notwithstanding, continue in full legal force and effect.
Initial _______ CONTINUE WITH THE SIGNATURE PAGE
FAMU IS AN EQUAL OPPORTUNITY/EQUAL ACCESS UNIVERSITYIMPORTANT - READ ENTIRE AGREEMENT BEFORE SIGNING
______________________________________________
Participant name Printed:
____________________________________________________ ____________________________
Signature (if 18 years of age or older): Date:
__________________________________________________________________________________
Address:
___________________________________________________________________________________________
Telephone Number (s):
Pre-existing allergies, illness or injuries: _______________________________________________________________________
_________________________________________________________________________________________________________
___________________________________________________
Print name of Parent / Guardian (if Participant is under 18 years of age or a dependent child):
_________________________________________________ ____________________________
Signature: Date:
______________________________________________________________________________
Address:
__________________________________________________________________________________________
Telephone Number (s):
Emergency Contact Information for Participant
__________________________________________________________________________
Name:
________________________________________________________________________
Address:
_____________________________________________________________
Telephone Number(s):
Participant and Parent signatures need not be notarized but must be witnessed.
__________________________________________________
Witness name Printed:
___________________________________________________ ____________________________
Signature of Witness: Date:
_________________________________________________________________________________
Address:
_________________________________________________________________________________
Telephone Number (s):
**ORIGINAL DOCUMENT MUST BE KEPT IN THE OFFICE OF THE UNIT SPONSORING THE TRIP**
FAMU IS AN EQUAL OPPORTUNITY/EQUAL ACCESS UNIVERSITY2018 AgTech Century Summer Enrichment Program
Student Information Form
Students Information (Please type or print):
1. Child’s Name: ___________________________________________
Last First Middle
2. School: _________________________ 3. Grade: _____________
4. Social Security Number: ____-____-____ 5. Birth Date ____________
6. Gender: F _____ M_____
7. Ethnic Background (check only one):
_____ American Indian or Alaska native _____ Asian
_____ Black or African American _____ Hispanic or Latino
_____ Native Hawaiian/Pacific Islander _____ White
_____ Other (Please list)____________________________
8. Home Address:
_______________________________________________________
Street City ZIP
9. Home Phone: ________________________
10. Alternate Phone (Cell): _________________
11. Email Address: ________________________
12. Emergency Contacts:
____________________________________________________
Name Phone Relationship
______________________________________________________________________________
Name Phone Relationship
Health Insurance Information: (Please check one)
____No Coverage ____Group Plan ____Healthy Kids
____Medicaid ____Private Plan ____Other (Please list)
FAMU IS AN EQUAL OPPORTUNITY/EQUAL ACCESS UNIVERSITYFLORIDA A&M UNIVERSITY
OFFICE OF THE PROVOST & VICE PRESIDENT FOR ACADEMIC AFFAIRS
DIVISION OF CONTINUING EDUCATION
SUMMER PROGRAMS POLICIES AND RULES
Summer camp participant policies and rules include, but are not limited to the following:
1. Campers will be respectful of their peers and instructors and obey program staff.
2. Campers must report to their designated classes, activities and assigned areas on time and
comply with all curfews.
3. Campers will adhere to appropriate dress code (e.g. no halter tops, tube tops, bare backs, shirts
that show cleavage and midriff, excessively baggy or tight fitting clothes, sagging pants, clothing
that displays profanity, vulgar, discriminatory, suggestive language, promotes in any way gang
affiliation, tobacco, alcohol, drugs, or any other way distracting, no hats or do-rags are to be
worn in buildings other than the dorm.)
4. Campers will wear appropriate identification at all times. This includes a camp identification
card with a lanyard worn around the neck. Additionally, as a safety measure, camp identifying
apparel (T-shirts, hats, etc…) will be worn when campers are participating in activities away from
the University.
5. Campers will not be permitted to wander around the campus unsupervised. They will have an
escort (counselor, mentor, or resident advisor) with them at all times.
6. Campers are prohibited from engaging in, but not limited to, the following:
a. Drinking alcohol, possession, using, or selling drugs, and smoking cigarettes. Only
medications prescribed by a physician are permitted. If camp participants have
prescription drugs, make sure the director and staff are aware of the medication;
b. Fighting, using profanity, gambling, or possession of any type of weapon; fireworks,
lighters, or matches ;
c. Hazing, bullying (verbal and/or physical abuse or cyber-bullying), or harassment;
d. Tampering with emergency equipment (including but not limited to fire alarms);
e. Having members of the opposite sex in their rooms;
f. Displaying aggressive behavior or using profanity, racial slurs, or insults;
g. Destroying FAMU or private property;
h. Leaving group activities without permission or distracting group activities;
i. Cheating or sleeping in the classroom;
j. Stealing or robbery;
k. Using cell phones in the classroom, study sessions, or structured activities;
l. Having visitors on campus, especially in the dorms. Female campers will reside in the
girl’s dorm and male campers will reside in the boy’s dorm. Parents/Guardians may visit
with staff permission;
m. Playing late-night video games;
n. Leaving the campus or designated site without permission. No one without express
permission and a PICTURE ID (including camp staff) is allowed to pick up a camp
participant; only with permission and proper identification can the camper be picked up
from a designated site; and
FAMU IS AN EQUAL OPPORTUNITY/EQUAL ACCESS UNIVERSITYo. Participating in such University activities as Freshman Orientation parties or fraternity
and/or sorority parties.
7. Campers will not engage in hazing activities. There is zero tolerance for HAZING. It is the policy
of Florida Agricultural and Mechanical University (BOT Regulation 2.028) that any persons
affiliated with the Florida Agricultural and Mechanical University are prohibited from engaging
in any form(s) of hazing activities. Any persons having knowledge of or receiving information
regarding hazing or violation of the Regulation must report it to the FAMU Department of Public
Safety within 24 hours. The commission of such acts will incur penalties from the individual staff
or camper’s dismissal up to program suspension. Additionally, penalties may be imposed for
violation of criminal law as prescribed by s. 1006.63, Florida Statutes.
8. Campers must maintain sleeping area in a safe and sanitary manner (e.g. clean their rooms
daily).
9. All campers who will be leaving the program after an evening culminating activity must check
out of the dorm with __________ prior to the activity.
10. Each camper must have a signed Travel Authorization and a Medical Release Form on file.
11. All programs will have a centralized location for checking campers in and out. No parent,
guardian, sibling, or other relative will be permitted to pick up a camper without prior notice to
the Camp Director. The person picking up the camper must present a valid form of identification
and must be listed on the authorized pick up list. Parents and guardians will be informed of
these rules to avoid confusion and delays in checking out campers. No camper will be released
without notice and identification. Campers who are checked out by a parent or guardian must
be back at the dorm by a time specified at checkout. Emergencies will be the exception. There
shall be a head count conducted every night to make sure all campers are accounted for.
12. Campers are not permitted to have a car on campus. If they have jobs, they must make other
arrangements to get to the job site.
13. On October 1, 2012, new mandatory reporting child abuse requirements became effective in
Part III, Chapter 39, Florida Statutes. Such mandatory reporting requirements were made
applicable to colleges and universities, in addition to the pre-existing reporting duties.
Specifically, section 39.305, Florida Statutes, subjects colleges and universities to a $1 million
fine for each failure of its administrators and law enforcement agency to report known or
suspected child abuse, abandonment, or neglect committed on the property of the university or
during a university-sponsored event or function to the Department of Children and Families
(DCF). Pursuant to the above-referenced statute, the Florida Board of Governors promulgated
Regulation 3.002 to provide additional guidance to Universities on the issue. Section 39.305,
Florida Statutes and BOG Regulation 3.002 are incorporated herein by reference.
Summer programs take place on FAMU’s campus and program activities are considered
University-sponsored events or functions. Therefore, summer program representatives (e.g.
administrators, directors, counselors, faculty, staff, etc.) have a duty to protect our vulnerable
summer program participants by immediately reporting known or suspected child abuse,
abandonment, or neglect committed on the property of the university or during a university-
sponsored event or function. Reports shall be made to DCF, FAMU Department of Public Safety
and to Ms. Phyllis Watson, Director, Continuing Education.
FAMU IS AN EQUAL OPPORTUNITY/EQUAL ACCESS UNIVERSITYCONSEQUENCES FOR VIOLATING SUMMER PROGRAMS RULES
Class I Violations
• Tardy to class or activity
• Failure to report to an assigned area
• Leaving class without permission
• Loud talking or running in any building
• Cheating in class
• Inappropriate dress
• Unauthorized use of FAMU or other campers’ property
• Use of cell phone or any electronic device during structured activities
• Failure to maintain sleeping areas in safe and sanitary manner
• Disobeying program staff
• Failure to open room door for assigned program staff
Consequences of Class I Violations
• First Offense: Conference with student, director, and adult camp staff member.
• Second Offense: Conference with student, director, adult camp staff member, and
parent/guardian and denial of privileges.
• Third Offense: After meeting with director, adult camp staff member, and Summer Programs
coordinator, student will be immediately dismissed from the program for the remainder of the
summer.
Class II Violations
• Gambling or betting with money
• Profanity, racial slurs, insults, and bullying
• Unauthorized visitors on campus
• Personal car on campus
• Disruptive behavior during structured activities
• Un-escorted around campus at any time
• Pulling the fire alarm or tampering with emergency equipment
• Aggressive, disrespectful, and/or abusive behavior or lack of courtesy toward other campers
Consequences of Class II Violations
• First Offense: Conference with student, director, adult camp staff member, and
parent/guardian and denial of privileges.
• Second Offense: After meeting with director and/or adult camp staff member and Summer
Programs Coordinator, student will be immediately dismissed from the program for the
remainder of the summer.
Class III Violations
• Possession or use of alcohol or illegal drugs (Notify police)
• Possession or use of any kind of weapon (e.g. knives, firearms) (Notify police)
• Possession or use of fireworks, matches or lighters
• Possession or use of tobacco
• Fighting, threat of physical abuse or bullying (Police will be notified)
FAMU IS AN EQUAL OPPORTUNITY/EQUAL ACCESS UNIVERSITY• Leaving campus without permission
• Males entering female dormitory or females entering male dormitory
• Breaking curfew away from dorm
• Hazing (Police will be notified)
• Stealing or robbery
• Aggressive, disrespectful, and/or abusive behavior or lack of courtesy toward camp staff
• Intentional damage to private property or university facilities; vandalism/trespassing (Police will
be notified)
• Sexual behavior
• Parental harassment of staff or someone else’s child
Consequence of Class III Violations
After meeting with director, adult camp, staff member and Summer Programs Coordinator, student
will be immediately dismissed from the program for the remainder of the summer.
ACKNOWLEDGEMENTS
As a parent/legal guardian of a summer program participant, I understand and acknowledge that my
child’s participation in a summer program held at Florida A&M University requires adherence to specific
program rules, University summer program rules attached hereto and incorporated herein by reference,
applicable University regulations and policies, and state and federal law. The summer program
representative, University official, and/or law enforcement will be the sole determiner of whether my
child’s actions are in violation of the aforementioned. If my child’s actions are in violation of specific
program rules, University summer program rules, applicable University regulations and policies, or state
and federal law, my child’s participation in a summer program may be terminated.
I understand and acknowledge that should my child’s participation in the program be terminated, my
child is required to leave the program immediately and I am solely responsible for arranging and paying
for my child’s transportation back home, and I will receive no refund of any fees. Should I refuse to
arrange and/or pay for my child’s transportation after termination from the program, I understand and
acknowledge that my failure may constitute child abandonment and statutorily requires Florida A&M
University to report the incident to the Florida Department of Children and Family Services and my child
will be delivered/transported to the appropriate State authority.
I have read and understand these policies, rules, violations and consequences and agree to follow them
during the entire summer camp.
____________________________________________________________________________
Camper’s Signature Date
I understand these policies, rules, violations and consequences and agree to support Summer Program
Staff in implementing them in regards to my child. I accept responsibility for explaining these rules and
consequences to my child and further accept responsibility for my child’s actions and will take
appropriate action to make sure his/her behavior is acceptable during this camp.
____________________________________________________________________________
Parent’s Signature
FAMU IS AN EQUAL OPPORTUNITY/EQUAL ACCESS UNIVERSITYCode of Conduct
RULES
• Must stay with your assigned group
• No leaving campus without supervision
• No fighting
• No inappropriate behavior
• No inappropriate attire
• No obscene language
• Treat fellow peers and counselors with respect and common
courtesy
• Do not bring any inappropriate materials or items
• *Absolutely no drugs (including cigarettes) or alcohol
*You will be sent home immediately if this rule is
violated
Student
I _____________________ (students name) have read and understand the above
rules and I am aware that I will be sent home if these rules are violated.
________________________ ______________
Students Signature Date
Parent
I _____________________ (parents name) have read and understand that if my
child violates the rules I will be asked and required to come and pick up my child from
camp at Smith Williams Center, Tallahassee, FL
_________________________ ______________
Parents Signature Date
FAMU IS AN EQUAL OPPORTUNITY/EQUAL ACCESS UNIVERSITYPARENT AUTHORIZATION/QUESTIONNAIRE FOR SUMMER PROGRAM
2018 AgTech Century at Florida A&M University
1. I will allow my child to be photographed/video taped for the purpose of
promoting or advertising this program.
_______Initials
2. I will allow my child to be transported by CAFS Staff for camp activities/field
trips.
________Initials
3. List any allergies your child has (food, medications etc.):
_______________________________________________________
_______________________________________________________
_______________________________________________________
4. If your child has a headache or they report any pain or soreness can they be given
the recommended amount of Ibuprofen?
______Yes ______No
If no, please send approved pain reliever with them, with instructions.
5. Is your child taking any prescription medications? _____Yes ___No
If yes please list what medications and what are they for.
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
END OF FORMS
FAMU IS AN EQUAL OPPORTUNITY/EQUAL ACCESS UNIVERSITY2018 AgTech Century 21
Schedule Overview
Note: Activities will start on Monday and continue thru Friday.
Sunday, July 15, 2018 Orientation/Meet & Greet
Monday, July 16, 2018 TBA
Tuesday, July 17, 2018 TBA
Wednesday, July 18, 2018 TBA
Thursday, July 19, 2018 TBA
Friday, July 20, 2018 TBA/Closing Ceremony
FAMU IS AN EQUAL OPPORTUNITY/EQUAL ACCESS UNIVERSITYEND OF APPLICATION FAMU IS AN EQUAL OPPORTUNITY/EQUAL ACCESS UNIVERSITY
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