Application Form

Health Science Camp

July 11-16, 2010

First Nations University of Canada

Department of Science

Department of Indian Education

Regina Campus

Health Science Camp 2010 Application Form

Student's Full Name:____________________________________________________________________

Address: Street___________________________________ Province:________ Postal Code:__________

Email: ___________________________________________________________

Please check (þ) those that apply:

¨ First Nations ¨ Metis ¨ Inuit ¨ Other:________________

Band Affiliation (if applicable):__________________________ Treaty #:_______________________

Date of Birth (year/month/day): _______/________/_______

(The camp is targeted for students in grade 8 to 12 and under 18 years of age.)

Grade _____

Male _____ Female_____

MEDICAL INFORMATION: (To be completed by parent or guardian if under the age of 18)

Does your son/daughter have any known illness/condition/allergy? Yes / No

If so, are they taking medication prescribed by a physician? Yes / No

Describe the nature of the illness/condition/allergy and medication schedule:

_____________________________________________________________________________________

Are there any known heart/respiratory illnesses or disabilities that would prevent your son/daughter from participating in a physically active curriculum? Yes / No

Physician name and telephone#: ___________________________________________________________

Emergency Contact #1 (parent/guardian) __________________________________________________

Home Phone#____________________________________ Work Phone# _________________________

Emergency Contact # 2 (relationship) ____________________________________________________

Home Phone #____________________________________ Work Phone# _________________________

HOSPITALIZATION/Health Insurance Number: __________________________________________

APPLICANT CONSENT FORM

** TO BE COMPLETED BY PARENT /GUARDIAN IF STUDENT IS UNDER THE AGE OF 18**

I_______________________________ give consent for my child_______________________________

to attend the 2010 First Nations University of Canada’s Health Sciences Camp at the University of Regina campus.

I understand the First Nations University of Canada is responsible for costs related to supervision, accommodations, meals, and camp activities. Travel costs to and from the university are the responsibility of the student or their sponsor.

I understand that any costs outside of the camp are the responsibility of the student or their sponsor.

I understand that the parent/guardian and student will be responsible for remuneration due to any possible damages sustained to the university property by the student as a result of unlawful behaviour.

I consent to the use of any necessary first aid or medical attention during the week of camp.

I consent to the usage of digital photographs & video footage to be used in the final report and as promotional material in published, web and broadcast formats for future camps.

I understand that my child will be sent home at the cost of the parent/guardian or student if inappropriate behaviour or misconduct occurs.

I understand that the First Nations University of Canada does not assume responsibility and are not liable for accidental injury sustained by the student during camp.

I have read the above and agree with the terms as outlined. I fully understand the responsibilities of both the parent/guardian and student.

__________________________________________ _______________________________________

Parent/Guardian signature Date

As part of the screening and evaluation process we ask that the students submit a summary describing some achievements, goals and aspirations. We want to know how you think this camp will help you on your educational path towards a career in Health and Science.

(Please feel free to complete this sheet or attach a typed written sheet.)

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please provide a recommendation from a teacher, education counsellor or community leader.

(Please feel free to complete this sheet or attach a typed written sheet.)

Name:_____________________________________________

Position/Title:_______________________________________

Comments:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Signature:____________________________________

Please check some activities you may be interested in doing while at the Health Science Camp:

Swimming ____ Medicine Wheel Walk ____ Camp-in at Science Center ____

Sweatlodge ____ Beading ____ Bannock Making ____

Hospital tour ____ Wascana Bird Sanctuary ____ Movie Night ____

Bowling ____ Kayaking ____ SaskPower tour ____

Please write down other activities if they are not listed above: __________________________________________________________________________________________________________________________________________________________________________

APPLICATION FOR THE 2010 HEALTH AND SCIENCE CAMP

Please return the completed application to the address below by mail, fax or email.

Health and Science Camp Coordinator

Department of Science

First Nations University of Canada

1 First Nations Way

Regina, Saskatchewan, S4S 7K2

Phone # (306) 790-5950 Ext. 3325

Fax # (306) 790-5993

Email: science@firstnationsuniversity.ca

http://www.firstnationsuniversity.ca/default.aspx?page=30