140922 - Robotics Liability Release - Build Space Provider - BRHS 2014-2015

TEST Team 303TEST Team 303 Student:___________________________Student:___________________________

Bridgewater-Raritan High SchoolBridgewater-Raritan High School

TEST TTEST TEAMEAM 303 303 WAIVERS WAIVERS

ANDAND CONSENT FORMS CONSENT FORMS

1 PARENT/GUARDIAN LEGAL CONSENT FORM FOR MEDICAL TREATMENT.........................................32 LIABILITY RELEASE FORM [RELEASE OF ALL CLAIMS AGREEMENT]................................................................43 CONSENT FORM FOR PUBLISHING STUDENT PHOTOGRAPHS...............................................................54 RULES AND REGULATIONS FOR ROBOTICS TEAM TRIPS/ACTIVITIES..................................................6

4.1 “Gracious Professionalism At All Times”...............................................................................................64.2 Rules...................................................................................................................................................................64.3 Behavior/Conduct...........................................................................................................................................64.4 Language and Gestures...............................................................................................................................64.5 Curfew................................................................................................................................................................64.6 Proprieties.........................................................................................................................................................74.7 Transportation.................................................................................................................................................74.8 Swimming.........................................................................................................................................................7

5 CONTACT INFORMATION POLICY......................................................................................................................86 PARTICIPATION POLICY........................................................................................................................................8

6.1 Grades................................................................................................................................................................86.2 Active Participation.......................................................................................................................................8

7 CARPOOLING POLICY............................................................................................................................................98 ADDITIONAL RELEASE FOR PARENTS, GUARDIANS, AND SIBLINGS...................................................99 STUDENT AND PARENT INFORMATION FORM.............................................................................................910 PARENTAL TALENT.............................................................................................................................................911 RELEASE FORM SIGNATURE PAGE.............................................................................................................1012 MEDICAL QUESTIONNAIRE............................................................................................................................11

12.1 Insurance.........................................................................................................................................................1112.2 Emergency Contacts...................................................................................................................................1112.3 Student Health Information......................................................................................................................11

Directions:

o Please read all waivers.

o Please enter Information into “SIGNATURE PAGE”.

o Sign the “SIGNATURE PAGE”.

The signature page applies to all sections of this waiver

packet for Team 303.

Both parents, or legal guardians, must

initial where indicated and sign the final page for the releases,

unless parents are divorced, in which case the custodial

parent with sole legal responsibility only need sign.

TEST Team 303 – 2014-2015 Consent Forms

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1 PARENT/GUARDIAN LEGAL CONSENT FORM FOR MEDICAL TREATMENT

To Whom It May Concern: The undersigned does hereby give permission for my child,

(Print name of child)____________________________________________________________

to attend and participate in all activities and trips sponsored by Bridgewater-Raritan Regional High School (BRHS) Robotics, participating in FIRST Robotics and other events.

I authorize an adult in whose care the participant has been entrusted to consent to any and all medical, surgical, dental, diagnostic, examinations and treatment and hospital care to be rendered to the participant under the general or special supervision or advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at a hospital, as well as any emergency medical care that may be given at the scene, and transportation that may be necessary to provide medical care.

The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical and/or dental services rendered to the aforementioned child pursuant to this authorization.

I understand that an adult in charge of this event will attempt to notify me in the case of a medical emergency involving my child. However, in the event that I cannot be reached, I authorize the calling of a doctor and the providing of any and all medical services in the event my child is injured or becomes ill. I understand and agree that Bridgewater-Raritan Regional High School (BRHS) and any build space provider, its directors, employees, agents, and volunteers, including but not limited to, parent, mentor, machinist, and engineering volunteers, will not be responsible for any medical expenses incurred, but that such expenses will be my sole responsibility as parent/guardian.

I agree to notify the BRHS Robotics Team Staff in the event of any health changes, which might restrict my child’s participation in any activities. I also understand and agree that the adult supervisors reserve the right to restrict my child from any activity that they do not feel is within the capabilities of my child.

I, the undersigned, being the parent or legal guardian of the child named herein, do hereby consent to the participation of my child in all of the activities connected with Robotics team trips, including, but not limited to, all recreational activities (such as water activities, sports, games). Further, I certify that my child is physically fit and adequately trained and competent to participate in such events.


The undersigned does also hereby give permission for my child to ride in any vehicle designated by an adult in whose care the participant has been entrusted while attending activities for team sponsored events.

Should it be necessary for my child to return home due to medical reasons or otherwise, the undersigned shall assume all transportation costs.

BOTH parents please initial here and sign the signature page: ______ _______

2 LIABILITY RELEASE FORM [RELEASE OF ALL CLAIMS AGREEMENT]

In consideration for being accepted by the Bridgewater-Raritan Regional High School (BRHS) Robotics Team for participation in FIRST Robotics Competitions, we, being 22 years of age or older, do for ourselves and for and on behalf of our child-participant, do hereby release, forever discharge and agree to hold harmless BRHS, any build space provider, and the directors and employees and all volunteers, including but not limited to, parent, mentors, machinist, and engineering volunteers, and assigns thereof from any and all liability, claims, or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the child-participant that occur while said child is participating in any trips or activities regardless of location.

We understand that as part of the normal activities of the robotics team, our child-participant may be working with, near or be exposed to mechanical, electrical, and other industrial machinery that may cause injury. We accept these risks and agree that this release applies to all such injuries that may be sustained.

We and on behalf of our child-participant, hereby assume all risk of personal injury, sickness, death, damage and expense as a result of participation in travel, recreation, and work activities involved therein.

Further, authorization and permission is hereby given to BRHS to dispense any necessary medication that is provided in accordance with your written instructions.

The undersigned further hereby agree to hold harmless and indemnify said BRHS, Any build space provider, its directors, employees, agents, and volunteers, including but not limited to, parent, machinist, and engineering volunteers for any liability sustained as the result of acts of said participant, including expenses incurred attendant thereto.

If the participant has not attained the age of 21 years: We are the parents (or legal guardians) of this participant, and hereby grant our permission for him/her to participate fully in any and all trips and activities, and hereby give our permission to take said participant to a doctor or hospital, and hereby authorize medical treatment, including, but not in limitation to emergency surgery and medical treatment, and assume the responsibility of all medical bills. TEST Team 303 – 2014-2015 Consent Forms

Further, should it be necessary for the participant to return home due to medical reasons, disciplinary action, or otherwise, we hereby assume all transportation costs.

I have read all the aforementioned release of liability details, and the Rules of Conduct for participants (see attached statement), and I will abide by them, as well as any directions given to me by the leaders, advisors, volunteers, and engineers during team trips and activities.


3 CONSENT FORM FOR PUBLISHING STUDENT PHOTOGRAPHS

The BRHS Science Department and the BRHS Robotics Team maintain websites with a wide variety of resources. As a normal part of these websites, we include pictures of our students participating in various aspects of the Robotics Team including competition, construction, and other team related activities that occur during the school year, to which this consent form will apply.

We are occasionally asked to supply photographs for newspaper articles so that the team and the school can get the recognition and positive reinforcement it deserves. We also use pictures of students in print, video, CD-ROM, DVD and other media for documentation, presentation and public relations purposes. Further, we use video of students on CD-ROM, DVD and other media, including websites such as our team website and www.youtube.com.

By giving your permission to use any image of your child, you agree that it may be used during this school year and at any future time as well. Please note that our use of the words "picture" and "photograph" include all kinds of images, including but not limited to, digital, graphical and photographic.

We will not include your child's name with the picture unless you indicate below that you give your permission to do so. We will not use any photo of your child unless you indicate below that you give your permission to do so. However, if the picture contains other students for whom we have received permission to publish the photo, the image of your son/daughter will be blurred so that she, or he, cannot be identified.

I hereby give permission for picture(s) of my son/daughter to be used as described above.

3a. SIGNATURE REQUIRED: Please sign Signature Page for this Consent for Publishing Photos!


I hereby give permission to include the name of my son/daughter to be printed with the images as described above. I understand that in some instances the surname will not be included with the photograph.

3b. SIGNATURE REQUIRED: Please sign Signature Page for this Consent for Publishing Photos with Students Name!

4 RULES AND REGULATIONS FOR ROBOTICS TEAM TRIPS/ACTIVITIES

4.1 “Gracious Professionalism At All Times”As chaperones/mentors for the Robotics Team, we think it is important to outline some of our expectations concerning student behavior during our trips and activities. We are making our requirements known to you in advance for your acknowledgement and pre-approval. If you are not willing and able to abide by the following rules, you will not be considered for inclusion in team activities. Those of us, who are responsible for maintaining student safety, as well as creating successful, meaningful, learning experiences, take this role very seriously.

Chaperones cannot assume complete responsibility for the actions of any one student should he or she choose to disregard the rules we have set in place. Each individual student is responsible for his/her own actions and the consequences for not following the rules. We want to you to understand that our directives for the students will be the same as they were our own children. We expect all students to respect our decisions and our authority.

4.2 RulesRegardless of age, all students will observe all the rules. This is a school-sponsored team; all BRHS School Rules apply at all times. Disregard for these rules will result in disciplinary consequences while at the activity and further consequences when we return back to school.

4.3 Behavior/Conduct Each student is responsible for his/her own behavior. Students are expected to behave in a manner that represents BRHS, our community and your family. Students must keep noise level appropriate at all times, especially in hotels, airports and public places. Students will be respectful and considerate towards others.

4.4 Language and GesturesStudents are expected to act like ladies and gentlemen at all times. No profane, obscene, or offensive remarks, noises or gestures will be tolerated. Any student who violates this rule will be remanded to his/her hotel room when TEST Team 303 – 2014-2015 Consent Forms

the day’s activities are complete. Students repeatedly violating this rule will be sent home at the parent’s expense.

4.5 CurfewCurfew will be determined by the chaperones, as appropriate for the day’s activities. When staying overnight, room checks will be made each night by the chaperones. Student must remain in their room after curfew. Curfew times will be announced each evening, depending on the plans for that evening and next day. Unless an emergency circumstance warrants, students must be on time for curfew. If a student is repeatedly late without sufficient and compelling reason(s), that student will be remanded to his/her own room as soon as the day’s activities are complete, and further consequences may have to be implemented. If the behavior persists, the students will be sent home at the parent’s expense.

4.6 ProprietiesBoys shall not be allowed in the girl’s rooms or vice versa at any time during the trip. If students want to socialize this must be done elsewhere, in-group settings. If an impropriety occurs, all students involved will be immediately sent home at your expense. At no time will a student be allowed to accept a date or invite “outsiders” (non-BRHS Team Participants) to our hotel for any reason. Student violating this rule will be sent home immediately at your expense.

4.7 TransportationStudents are not permitted at any time to enter any vehicle of anyone other than the appropriate transportation contracted by BRHS Robotics Team. This includes any/all forms of transportation/watercraft, etc. There may be times that the group will use public transportation but this is to be done as a group with a chaperone present. Students violating this rule will be sent home at their parent’s expense.

4.8 SwimmingStudents will not be allowed to engage in swimming/snorkeling/water related activity unless it is a pre-approved group activity. Students are never allowed to swim alone.

4.9 Zero ToleranceThe following will not tolerated at all in any Robotics Activity and student will be sent home at the parent’s expense:

Consumption of alcoholic beverages Illegal use of non-prescription/prescription drugs. Prior notification of all

medications must be done before any Robotics Events/Meetings. Smoking

I, ____________________________________(Student Signature) have read the Rules and Regulations for the Robotics Team. I agree to obey them. I agree to obey the directions of the chaperones throughout any Robotics Activity/Trip. I understand that failure to obey the rules will result in disciplinary action, which may include being sent home at my parent/guardian expense.TEST Team 303 – 2014-2015 Consent Forms

Each and every Parent/Guardian must sign that he/she accepts the responsibility for their student’s behavior and agrees to accept financial responsibility for all expenses we incur, if it becomes necessary for us to send the student home early.


5 CONTACT INFORMATION POLICY Sharing of contact information among the team members greatly enhances our ability to work as a team, facilitating activities such as carpooling, etc. This information will not be posted publicly, but will be listed privately in certain locations, such as password protected areas on the team website. I agree to allow contact information for my child’s and my phone number, address, and e-mail address to be shared among team members and their parents through hardcopies or electronic copies. I also agree that I will not use this list for distribution of information other than robotics-related material, such as spam or solicitations. Violations may impact the student’s position and membership on the team. I would like our contact information to remain private from the team distribution list.

5a. SIGNATURE REQUIRED: Please sign Signature Page for this Contact Information Policy!

6 PARTICIPATION POLICY Team 303 is hard work, and everyone is expected to chip in and pull their weight. There are certain minimum academic and participation requirements that determine a student’s eligibility to remain on the team. Seeing the season through will provide a great feeling of accomplishment.6.1 Grades – Required for travelStudents must maintain a B- or better average in all classes. Students must have all their teachers sign off that they meet these criteria before they can go to a FIRST Regional or Championship Competition, and it is at the teacher’s discretion whether the time away from school will affect their ability to keep up in each class. If a student is in danger of failing a course, he or she is expected to put forth the required effort to improve his or her grades. This includes staying after school for extra help, possibly receiving peer tutoring from other team members and completing all homework assignments.


6.2 Active Participation – Required for travelEach student must attend a minimum of 50% of pre-season meetings. They must attend 75% of all build season meetings, or 75% of their sub-teams meetings during the build season, excluding team social events. Fundraising is important to the sustainability of the team, and also helps provide great team building activities. Each student is expected participate in at least 75 % of fundraising events. All parents will be required to help during our fundraising events. The student must not be disruptive and should make an effort to contribute to the team. Failing to meet these terms may negate the student’s eligibility to travel to competitions or result in expulsion from the team.

I have read the statement regarding participation requirements and agree to its terms.


7 CARPOOLING POLICY

Occasionally, parents, mentor and other students transport team members to or from events and meetings to enable a greater participation level. This carpooling is considered at your own risk, and is in no way connected to the high school, or FIRST. Drivers should only offer such rides if they have valid licenses and appropriate insurance. All passengers should have available, and use, seatbelts.

7a. SIGNATURE REQUIRED: Please sign Signature Page for this Carpooling Policy!

8 ADDITIONAL RELEASE FOR PARENTS, GUARDIANS, AND SIBLINGS

When parents, guardians, and siblings enter the buildings at any build site to pick up and drop off students, or spend time there to help the team, they accept the same release of liability that applies to their student as outlined in items 1 and 2 above, as well as any other applicable section.

8a. SIGNATURE REQUIRED: Please sign Signature Page for this Additional Release!

9 STUDENT AND PARENT INFORMATION ON-LINE FORM

Please enter your information in our on-line form at the link which will be provided to you by an email from the team Advisor or as otherwise directed.


This form helps us consolidate data quickly, and allows us to be able to get information out to you faster.

10 PARENTAL TALENT

Team 303 draws on the talents and volunteer efforts of the many supportive parents of its members. From providing dinners during build season, to helping supervise students, to fundraising, to actually Mentoring students, 303 is supported by many adults. Please let us know any areas that you may be able to provide some assistance or expertise by providing this information in the online form. This is not required, but encouraged

Robotics Parent Association - RAMP

(Robotics Alliance of Mentors and Parents, Inc.)Team 303’s Parents and Mentors have formed an organization to provide support to Team 303 and its Teacher Advisor. RAMP helps by providing organizational and manpower support for fundraisers, trips, social events, etc. as well as endeavoring to interest adults in Mentoring the team in the many areas of activity. Annual dues to join and become a voting member are $ 10.00The team definitely depends greatly upon RAMP

11 RELEASE FORM SIGNATURE PAGE

Print Student Name: _______________________________________________________

We have read, understand, and agree to the following policies and releases:

1. Guardian Consent for Medical Treatment

2. Liability Release Form

3. Consent for Publishing Student Photographs No initials indicates non-consent.

a. Consent for Publishing Student Photographs

Initials__________ Yes, I grant permission.

b. Consent for Publishing Student Photographs with student’s name

Initials__________ Yes, I grant permission.

4. Rules and Regulations

5. Contact Information PolicyInitials__________ Yes, I grant permission allow contact

information for my child’s and my phone number, address, TEST Team 303 – 2014-2015 Consent Forms

and e-mail address to be shared among team members and their parents.

Initials__________ No, please keep my contact information private.

6. Participation Policy

7. Carpooling Policy

8. Additional Release for Parents, Guardians, and Siblings.

Signatures:

Student: Date:

Parent/Guardian: Date:

Parent/Guardian: Date:


12 MEDICAL QUESTIONNAIRE

STUDENT NAME: __________________________________________________________

HOME ADDRESS: __________________________________________________________

CELL PHONE NUMBER: _____________________________________________________

BIRTH DATE: _________________EMAIL:_______________________________________

12.1 Insurance

Is the participant covered by Medical/Hospital Insurance? (Circle one) YES NO

Health Insurance Company

Name of Insured Policy Number

Physician’s Name Phone ( ) -

12.2 Emergency Contacts

Please provide at least two emergency contacts (other than folks living in your home):

Name Relationship Phone ( ) -

Name Relationship Phone ( ) -

12.3 Student Health Information

Please answer all the following questions. If a question does not apply, please indicate “not applicable”.

List any additional information that you feel may be helpful to the care of your child at the end of this form, then sign and date where indicated.

Date of child’s last tetanus shot

Prescription Medications that child will be taking during any Robotics activities:

Medication Name Dose Times/Day to be taken

Condition being treated


Emergency medications (including over the counter) that your child might be taking during Robotics activities:

Does your child have your permission to take medication without adult supervision?

yes or no

Allergies:

To medications:

Other:

Special Diet Requirements: yes or no

Does your child have any of the following conditions:Seizure Disorder

yes no Asthma yes no

Heart Murmur

yes no Diabetes yes no

Kidney Disease

yes no Hay Fever yes No

Other:

Does your child have any condition, handicap, illness, or injury that would prevent fully participating in a normal rigorous activity? yes or no

Is there anything else that you would like us to be aware of regarding your child’s care and safety?

____________________ Parent/Guardian 1 (Print) Phone

Signature Date


____________________ Parent/Guardian 2 (Print) Phone

Signature Date


Documents

140922 - Robotics Liability Release - Build Space Provider - BRHS 2014-2015