EcoLab: Solve the Water Crisis

Thank you for your interest in the EcoLab: Solve the Water Crisis Summer Camp!

STOP & READ BEFORE PROCEEDING

If you are under 19 years of age, a parent or legal guardian must complete this form on your behalf. This form will take approximately 15 minutes to complete. For the best experience, we recommend using a laptop or desktop computer.

Please note that your progress cannot be saved, so be sure to complete the form in one sitting and do not exit your browser until it has been submitted.

This year’s camp is FREE and limited to 30 students and registrations will be accepted on a first-come, first-served basis. Students entering grades 7-12 are welcome to register.

Questions? Call Heather Conti : 419-530-7824

Student Contact Information

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Parent Information

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Emergency Contact Information
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College Plans

What grade will you be in Fall 2026?

Do you plan to take College Credit Plus classes?

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When do you plan to start College Credit Plus classes?

CCP Hidden Program

Enrollment Information (upon high school graduation, your college plans)

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School Information

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Enter your school's name or CEEB code. Then, select your school from the resulting list. If you are home schooled – please enter homeschool as all one word and select Homeschool from the dropdown list.

Additional Information

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Travel Information

I will arrive in Toledo on (date/time):

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I will depart Toledo on (date/time):

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Please indicate whether you plan to keep a vehicle on campus:

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Participant Name

Participant Signature

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A parent or guardian must sign this form for a minor under the age of 19.

Parent Name

Parent Signature

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Youth Program/Camp Medical Information Release Form

As a student, parent or guardian I understand that the information requested on this form is intended to help inform program staff of any pre-existing medical conditions. If Participant has a pre-existing medical condition, participation in any strenuous activities or recreational time may not be recommended. This information will be kept in strict confidence and will only be shared with your permission. The University of Toledo requests the information below so that, in case of emergency, we will have accurate information so that we can provide and/or seek appropriate treatment for Participant. You are accountable for providing an accurate medical history. Final determination about whether to participate is the responsibility of you and your physician. If Participant has any medical issue that is not requested below, but which you think is important, please include that information. It is recommended that you consult with a physician prior to participating in this Program. If you are uncertain about any preexisting medical conditions, it is your responsibility to consult with your own physician prior to participating in this Program. Please answer all of the questions. If you answer yes to any of the following questions, please explain as indicated. Use back and/or additional paper if needed.

Physician's Name:

Physician's Phone Number:

Date of most recent tetanus toxoid immunization:

Do you have health/accident insurance?

Yes

No

If yes, please indicate the name and address of insurance company:

Policy Number:

Does participant have any limiting medical conditions that you or your doctor feel would limit camp participation?

Yes

No

If yes, identify and explain.

Is participant currently taking medication that may interfere with ability to safely participate in Program?

Yes

No

If yes, please indicate the medication and the condition being treated.

Does participant have a history of allergies or reactions to medications, insect stings, or plants?

Yes

No

If yes, please explain.

Does participant have a history of, or currently suffer from, medical condition(s) with which we need to be aware?

Yes

No

If yes, please explain.

Unless prior arrangements have been made, medical needs will be handled through the University of Toledo Medical Center. In cases where medical attention is necessary, parents will be contacted for approval when possible. However, before medical treatment can be provided, we are required to have a medical release signed by the parent/guardian. The hospital will not perform services unless this form is presented at the time of treatment.

Participant has my permission to receive medical attention in the event of illness or medical emergency while participating in this Program. I will assume the financial responsibility for any cost of health care for my child that may occur during this Program.

As a participant, parent, or guardian I understand and acknowledge that my failure to disclose relevant information may result in harm to Participant and/or others during this Program. By signing my name I represent and warrant that I have provided all materials and important information to the University of Toledo pertaining to my Participant’s medical, mental and physical condition and that it is accurate and complete. I agree to notify the University of Toledo of any changes in my mental, physical or medical condition prior Participant’s scheduled Program.

By revealing or disclosing the above medical information it will not be used by University of Toledo personnel or
employees to determine Participant’s ability to participate safely in activities. I understand that, if Participant chooses to participate in activities, he/she do so voluntarily and of his/her own accord and the final decision regarding participation is solely the responsibility of myself and Participant.

Participant Name

Participant Signature

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A PARENT OR GUARDIAN MUST SIGN THIS FORM FOR A MINOR UNDER THE AGE OF 19.

Parent Name

Parent Signature

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Parental/Guardian Authorization, Waiver and Consent for Self-Administration of Prescription Medication

This form must be completed fully in order for participants to self-administer required medication. A new medication administration form must be completed for each Program attended by the participant, for each medication, and each time there is a change in dosage or time of administration of a medication. Self medication requires licensed health care authorization and signature, and parent signature.

Yes, my child will need to take prescription medication while at the Program.

No, my child does not need to take any prescription medication while at the Program.

Please contact Heather Conti : 419-530-7824 to get the proper documentation to utilize your prescription medication during camp.

All prescription medications, including medications for conditions such as food, drug or insect allergies; diabetes; asthma; or epilepsy may be brought to the Program under the condition that the participant can self manage care and delivery of medication with written authorization to do so at camp by a licensed health care provider. Prescription medication must be in its original container labeled by the pharmacist or prescriber. Label must include the name, address and phone number for pharmacist or prescriber. Containers must hold only the amount required for the time the participant will be attending the Program.

Parental/Guardian Authorization, Waiver, and Consent for Over the Counter Medication

Over-the-Counter (OTC) Medication may at times need to be administered, if approval is indicated by the participant’s parent or guardian. Please complete the following section to save time if your child needs any of these OTC medications during his/her stay. Note: Unless we have parental authorization, we cannot administer ANY medications.

List any other approved over the counter drugs.

Program staff reserves the right to use generic equivalents when available for the name brand over-the-counter
medications listed above.

I understand that such administration will not be done under the supervision of medical personnel. I also agree that any first aid treatment may be given as needed.

Any condition which is associated with fever, significant inflammation, and/or does not respond to the above outlined treatment will be followed-up by a consultation with the student’s parents. Parent/guardian will be contacted if any conditions develop requiring treatment with any of the above over-the-counter medications that are not checked.

I understand that these over-the-counter medications are not necessarily kept on hand and available to be administered immediately.

I authorize the administration of over-the-counter medications to my child as indicated above. I shall indemnify and hold harmless the Program Staff. The University of Toledo, its Board of Trustees, Administration, Faculty, Staff, Student Leaders, and all other officers, directors, employees and agents against any claims that may arise relating to my child being administered the above indicated over- the-counter medications. I/We have legal authority to consent to medical treatment for the student named above, including the administration of medication at the above referenced program.

Participant Name

Participant Signature

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Parent Name

Parent Signature

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Youth Program/Camp Informed Consent

PLEASE READ THIS DOCUMENT CAREFULLY BEFORE SIGNING. THIS IS A LEGALLY BINDING DOCUMENT. THIS FULLY SIGNED FORM MUST BE SUBMITTED BY A PARENT OR LEGAL GUARDIAN BEFORE ANY CHILD IS ALLOWED TO PARTICIPATE IN THE ABOVE REFERENCED
PROGRAM/CAMP.

(Enter N/A in fields that are not applicable)

I, the undersigned, wish for my Child (hereafter “Child”) to participate in the above referenced youth program (hereafter “Program”) on the date(s) and location(s) indicated above and, in consideration for my Child’s participation, I hereby agree as follows:

I acknowledge, understand and appreciate that as part of my Child’s participation in the Program there are dangers, hazards and inherent risks to which my Child may be exposed, including the risk of serious physical injury, temporary or permanent disability, and death, as well as economic and property loss. I further realize that participating in the youth program may involve risks and dangers, both known and unknown, and have elected to allow my Child to take part in the Program. Therefore I, on behalf of my Child, voluntarily accept and assume all risk of injury, loss of life or damage to property arising out of training, preparing, participating and traveling to or from the Program. By executing this Release, it is fully understood that my Child may be exposed to COVID-19 and other infections. Similar to other highly contagious viruses, it is understood that it is possible to contract the COVID-19 disease, even if my Child complies with all health and safety measures as required by UToledo (defined below) and as recommended by the Centers for Disease Control and Prevention (“CDC”) and the Ohio Department of Health (“ODH”). It is understood that although UToledo is following the coronavirus guidelines issued by the CDC, ODH, and other experts to reduce the spread of infection, my Child can never be completely shielded from all risk of illness caused by COVID-19 or other infections.

In consideration for my Child’s participation in the above captioned event, I, the undersigned parent/guardian of the minor child indicated below, hereby grant to the University of Toledo, its Board of Trustees, Administration, Faculty, Staff, Student Leaders, the Program Staff, and all other officers, directors, employees and agents (“UToledo”) the right to reproduce, use, exhibit, display, broadcast, distribute, exploit, modify, adapt, and create derivative works of photographs, videotaped images or video/audio recordings of my child (“Materials”) by incorporating them into publications, catalogues, brochures, books, magazines, photo exhibits, motion picture films, videos, electronic media, web sites, and/or other media, or commercial, informational, educational, advertising, or promotional materials or publications related thereto (“Works”). It is agreed that the Works will be used in connection with University business, the activities of the UToledo, or for promoting, publicizing or explaining University activities or events.

Materials may appear in any of the wide variety of formats and media now available to UToledo and that may be available in the future, including but not limited to print, broadcast, videotape, CD-ROM and electronic/online media.

I waive my right to inspect or approve any Works that may be created by UToledo using the Materials and waive any claim with respect to the eventual use to which Materials may be applied.

I understand and agree that UToledo is and shall be the exclusive owner of all right, title, and interest, including copyright, in the Works, and any commercial, informational, educational, advertising, or promotional materials containing the Materials. All electronic or non-electronic negatives, positives, and prints are owned by UToledo. I also understand that neither I nor my child will receive compensation in connection with the use of my child's image.

I, on behalf of my Child, hereby release UToledo from any and all liability as to any right of action that may accrue to my heirs or representatives for any injury to my Child or loss that my Child may suffer while training, preparing, participating and/or traveling to or from the Camp. This Release is binding on my heirs and assigns.
I, on behalf of my Child, furthermore release, indemnify and hold harmless UToledo from and against any and all liability, actions, debts, claims and demands of every kind whatsoever, specifically including, but not limited to, any claim for negligence or negligent acts or omissions and any present or future claim, loss or liability for injury to person or property that my Child may suffer, for which my Child may be liable to any other person, that may or does arise out of my Child’s participation in the Program, and out of the use of the Materials. I understand that UToledo accepts no responsibility for my Child’s personal property.

In the event of an accident or serious illness, I hereby authorize representatives of UToledo to obtain medical treatment for my Child on my behalf. I hereby hold harmless and agree to indemnify UToledo from any claims, causes of action, damages and/or liabilities, arising out of or resulting from said medical treatment. I further agree to accept full responsibility for any and all expenses, including medical expenses that may derive from any injuries to my Child that may occur during his/her participation in the Program.

This Release shall be governed by and construed under the laws of Ohio. I agree that any legal action or proceeding relating to this Release, or arising out of any injury, death, damage or loss as a result of my Child’s participation in any part of the Program, shall be brought only in the Ohio Court of Claims.

This Release contains the entire agreement between the parties to this Release and the terms of this Release are contractual and not a mere recital. The information I have provided is disclosed accurately and truthfully. I have been given ample opportunity to read this document and I understand and agree to all of its terms and conditions. I understand that I am giving up substantial rights (including my right to sue), and acknowledge that I am signing this document freely and voluntarily, and intend by my signature to provide a complete and unconditional release of all liability to the greatest extent allowed by law. My signature on this document is intended to bind not only myself and my Child but also the successors, heirs, representatives, administrators, and assigns of myself and my Child.

Participant Name

Participant Signature

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A parent or guardian must sign this form for a minor under the age of 19.

Parent Name

Parent Signature

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The University of Toledo Admission

page title

EcoLab: Solve the Water Crisis

Please contact Heather Conti : 419-530-7824 to get the proper documentation to utilize your prescription medication during camp.