NSHS Summer Program Registration

Hello Freshmen & Sophomores!

The Vincennes Early College Program is offering a Summer Program designed for our early college high school sophomores and freshmen. The program will be held at North Side High School. We will offer fun, engaging activities to help you explore new interests and develop college & career readiness. You’ll be able to enjoy the excitement of guest speakers and enriching activities without the pressure of grades.

You’ll hear from local community leaders and college admissions teams on topics to help prepare you for success in high school, college, and beyond. Most importantly, our program will help inspire you to dream big and to think creatively about your future.

Lunch will be provided

Seating is limited. Students will not receive high school or college credit for this 4-day program, and work will not be grade. Students who are not enrolled in the Vincennes University Early College Program can register for this summer program, but we encourage these students to contact Felisa Cockrell (Felisa.Cockrell@vinu.edu) for more information about the Early College Program.

Supplies Needed:

For daily physical activity, students will want to wear comfortable clothes and walking shoes. Devices (laptops, etc.) are encouraged but not required.

LOCATION

North Side High School

Enter at Door 1

475 E State Blvd,

Fort Wayne, IN 46805

WHEN: Two 4-day sessions to choose from. Select Only One:*

Monday, June 20 – Thursday, June 23; 10:00am – 3:00pm

Monday, June 27 – Thursday, June 30; 10:00am – 3:00pm

Student Information

First Name*

Last Name*

Student's Email Address*

Grade Level (starting Fall 2022):*

Student's Birthdate:

Student's Gender:

Citizenship*

Non U.S. Citizen-Intern F1 VISA

Permanent Resident/DACA TPS

U.S. Citizen

Undocumented

Race*

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White or Caucasian

Ethnicity*

Not Hispanic or Latino

Hispanic or Latino

Parent/Guardian Information:

First Name*

Last Name*

Parent/Guardian Email:*

Parent/Guardian Phone:*

Transportation will NOT be provided. We are offering free Citilink bus passes to those who request them.

Will you need CitiLink passes to and from North Side?*

Yes

No

Mailing Address:

Street:*

City/State:*

Zip Code:*

What are your reasons for wanting to participate in the Summer Program?*

Emergency Contact

Emergency Contact First Name*

Emergency Contact Last Name*

Emergency Contact Relationship*

Emergency Contact Phone*

Emergency Contact Email*

Health Information

Allergies:*

Dietary Restrictions:*

Additional Information Our Team Should Know (Medical or otherwise):*

Approvals

Parental Consent*

I consent to having my student participate in Vincennes University Early College Summer Program at North Side High School.

I agree to hold Vincennes University and its parties harmless from all losses, liabilities, or damages incurred while using CitiLink transportation or carpooling.

I agree to collect my student by no later than 3:30pm. Parents/Guardians of students who are not collected at the end of the scheduled program time, will be contacted. In the event that a parent/guardian cannot be contacted or is unable to collect their student, the student will be provided with a CitiLink bas pass to return home.

I agree that I am responsible to collect my student in the event that the student is suspended from the program. If I am unable to collect my student, I agree that the student will be provided with a CitiLink bus pass to return home. Behaviors that may warrant suspension or dismissal include but are not limited to:

COVID Protocols*

I agree to follow VU's policies regarding mask usage, frequent hand washing/sanitation/hygiene practices, social distancing along with the policies related to reporting and contact tracing. I will observe instructional signs and information provided on VU's website regarding the coronavirus information and heed all updates. I promise to protect myself and other in the VU community.

Liability Waiver

In consideration of permission granted by Vincennes University allowing me to participate in the Vincennes University/Summer Program at North Side High School 2022 (the "Activity"), which will occur on selected dates between June 20 and July 14, 2022, which is sponsored by Vincennes University Early College Program, I (together with my parent or guardian, if I am under the age of eighteen (18) or under a legal disability) represent, covenant and agree, on behalf of myself and my heirs, assigns, and any other person claiming by, under or through me, as follows:

Liability Terms and Conditions*

1. I acknowledge that participating in the Activity involves certain risks (some of which I may not fully appreciate) and that injuries, death, property damage or other harm could occur to me or others. I accept and voluntarily incur all risks of any injuries, damages, or harm which arise during or result from my participation in the Activity, including any associated travel, regardless of whether or not caused in whole or in part by the negligence or other fault of Vincennes University Staff, The Trustees of Vincennes University, and/or its or their departments, trustees, affiliates, employees, officers, agents or insurers ("Released Parties").

2. I waive all claims against any of the Released Parties for any injuries, damages, losses or claims, whether known and unknown, which arise during or result from my participation in the Activity, regardless of whether or not caused in whole or part by the negligence or other fault of any of the Released Parties. I release and forever discharge the Released Parties from all such claims.

3. I agree to indemnify and hold the Released Parties harmless from all losses, liabilities, damages, costs or expenses (including but not limited to reasonable attorneys' fees and other litigation costs and expenses) incurred by any of the Released Parties as a result of any claims or suits that I (or anyone claiming by, under or through me) may bring against any of the Released Parties to recover any losses, liabilities, costs, damages, or expenses which arise during or result from my participation in the Activity, regardless of whether or not caused in whole or part by the negligence or other fault of any of the Released Parties.

4. I have carefully read and reviewed this Waiver, Release And Hold Harmless Agreement. I understand it fully and I execute it voluntarily.

Media Release*

By signing this document, I hereby assign rights to the photographs, video, and audio recordings, and transcriptions associated to Vincennes University. I hereby authorize the reproduction, copyright, exhibition, broadcast, and/or other distribution of said photos, video, audio, and transcriptions without limitation for the purpose of promoting Vincennes University and its related entities in video, audio, print, web, and other mediums.

Parent/Guardian Signature:*

Student Behavior Agreement:*

I understand the following behavior is expected of me while I am at the Vincennes University Early College Summer Program:

To show respect to all members of the learning community and cooperate with fellow students, teachers, volunteer helpers and the Vincennes Early College staff and team.
To have good manners at all times.
To be polite and courteous with your actions and conversations with others (do not use bad language). Remember to treat everyone the way you like to be treated.
To listen and respond to directions given by adults the first time.
To behave respectfully, without arguing, and cooperate when a staff member gives direction or makes a request. I understand that I will be given an opportunity to voice my concerns at an appropriate time if I do not agree with the request.
To resolve conflicts peacefully, and avoid fighting inside or outside of the summer program.
To take responsibility for my personal belongings and respect the property of others.
To refrain from bringing weapons, illegal drugs, controlled substances, etc. to camp.
To share information with VU staff that might affect the health, safety, or welfare of the summer program community.
To keep parents/guardians informed about program-related matters and make sure I give them any information sent home.
To use program materials/equipment in a safe manner so they’re not damaged or lost.
To refrain from bullying of any kind and inform a teacher if anyone bullies me.

I have read and understood the above information. I promise to follow these guidelines and be on my best behavior during summer camp.

Student Signature*

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NSHS SUMMER PROGRAM REGISTRATION

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