HEALTH SCIENCES SUMMER DAY CAMP

HEALTH SCIENCES SUMMER DAY CAMP JUNE 15–19, 2015

HIGH SCHOOL STUDENTS (rising 9th–11th graders)

COST: $500

LEARN THE FOLLOWING: Checking vital signs

Patient assessment techniques

Use of lift equipment simulations in the patient simulation lab

Learn how to walk with crutches, walkers and wheelchair mobility

VISITS TO: Charitable health clinics

The Nashville Zoo

HEAR FROM: Top health care professionals in the

Nashville area

AND SO MUCH MORE!

Are you passionate about changing lives?

Have you ever wondered what a career is like as a health care professional?

BELMONT UNIVERSITY HEALTH SCIENCES SUMMER DAY CAMP

Presented by the College of Health Sciences and Nursing

and the College of Pharmacy

We are so glad you are considering coming to the Health Sciences Summer Day Camp this summer and we hope this information packet will be helpful in your camp planning! What Is the Health Sciences Summer Day Camp? The Health Sciences Summer Day Camp is a program designed to help students experience some of the excitement of being a health professional, meeting multiple health care professionals, and having a great time doing it. Health Sciences Summer Day Camp staff take care of the details and planning. During the day, students will be challenged by working alongside students and leaders from multiple disciplines. Purpose The program will provide high school students the rare opportunity to experience the “beat and pulse” of many different medical professions. Building upon Belmont University’s broad “footprint” in health care, this camp is designed as an inter-professional learning experience for students to become acquainted with pharmacy, nursing and physical therapy. Students attending camp will engage in high-interest, low pressure, non-credit enrichment experiences with a heavy emphasis on group interaction and collaborative problem solving in the medical arena. Along with classroom, laboratory, drug information, and simulation learning centers, students will also take field trips to interact and learn from various health care practitioners. Registration Fee and Deadline $500 due by May 15th Must be postmarked by this date. Checks should be made payable to Belmont University. Students may reserve a spot at camp any time before May 15, 2015 by submitting the registration fee* and application form to the following address: Belmont University College of Pharmacy Attn: Health Sciences Summer Day Camp Camps (please write camper name on all mail) 1900 Belmont Blvd Nashville, TN 37212 *Registration fee includes snacks and daily lunch, transportation to and from sites, a camp t-shirt and materials for all activities. Registration June 15, 8:00 AM-8:45 AM Camp will start promptly at 9:00 AM PLEASE NOTE: There are only 30 camper spots available. Once the camp meets capacity, we will be unable to accept additional campers. You will receive a confirmation email informing you of acceptance once we receive both your registration fee and application form.

ARRIVAL AT CAMP

Location Belmont University, McWhorter Hall (Bldg #7 on the map below) 1st Floor Lobby 1900 Belmont Blvd Nashville, TN 37212 Health Sciences Summer Day Camp Logistics Contact Erin Wikle, Assistant to the Dean, College of Pharmacy (615) 460-6538 or erin.wikle@belmont.edu Parking The North Garage is located on Acklen and 15th Avenue, just off of Wedgewood Avenue, underneath building #7 indicated on the map below. You may park in any open space without penalty. Once you’ve parked, take the McWhorter elevator to the 1st floor of McWhorter Hall. Pick-up and Drop-off area Campers can be picked up and dropped off at the roundabout at the southeast corner of McWhorter Hall, between building #s 8 & 9 indicated on the map below.

What to bring When students arrive at camp this summer, each should bring the following items:

Two Health Sciences Summer Day Camp Release Forms

Two photocopies of insurance cards attached for each camper o One of each of the above will be turned in to the Director of the Health Sciences Summer Day Camp

and the other will be given to the student’s assigned group leader.

Water bottle student can refill and carry

Spending money for bookstore (optional)

Any medicine the student needs What NOT to bring

• Alcohol, tobacco, illegal drugs, fireworks, water guns, or any kind of weapon • Anything that advertises alcohol, tobacco, or illegal drugs • Anything that • If students bring cell phones, please ensure these will not be a distraction at camp

Dress code Appropriate clothing is requested and we ask that students:

Wear sleeved shirts and modest shorts – when hands are extended to the back or the front, finger tips must

touch fabric

• Wear nice pants and a blouse/or dress shirt along with closed-toe shoes on days that students will be visiting clinics NOTE: Anything explicitly or implicitly promoting racism, sexism, refers to sexual actions or situations, or hatred of any group or person is not permitted.

Please do not wear:

• Spaghetti/small straps or open back shirts • Shorts or skirts that are excessively short, tight fitting or expose private areas • Clothing that allows others to see underwear (sagging your pants, rolling down your waistbands, etc.)

Transportation policy Students will be provided transportation when leaving campus to visit local clinic sites and the Nashville Zoo. Vans will be used for this purpose and all drivers will have been approved by the Belmont University Facilities Management Services. Special needs The Health Sciences Summer Day Camp takes the special needs of students seriously. Meeting each students needs are important to us. If a student has a special need that should be handled before camp starts, including, but not limited to: wheel chair accessibility, hearing/sight impairment, food allergies, etc., please call our camp toll-free line (615) 460-6538 and share this with our events registration team so it can be handled properly. The special need can also be communicated with us via email at erin.wikle@belmont.edu. Please let us know at least two weeks prior to the student’s arrival so arrangements can be made. If a student’s need should be known by our camp staff, there is an option to complete a “Special Attention Card” for your student so this need can be addressed by the Health Sciences Summer Day Camp staff. You can print and complete this card before camp or fill it out on registration day at camp. You can find a copy of this card attached with this document.

Adult leader qualifications & responsibilities

All adult leaders will be a current professional student in the College of Health Sciences and Nursing or the College of Pharmacy or is a full-time faculty member in one of the sponsoring colleges who have been appropriately screened for working with youth by Belmont University.

All leaders will meet the requirements set forth in the Statement of Compliance located in the forms section.

Adult leaders are responsible for working alongside and with students at all times.

Adult leaders will monitor dress code and behavior of students.

Adult leaders will encourage participation and promptness. Custom Health Sciences Summer Day Camp t-shirts All students will receive a camp T-shirt. Shirts will be distributed and group photos will be taken during one of the days of camp. Please be sure to include your preferred shirt size on your registration form. Camp schedule Over the course of the week, the students will be involved in following a case of a patient who was involved in a motor vehicle accident while driving under the influence of both alcohol and pain medications. The student will be involved in examining how each of the different health sciences field (pharmacy, physical therapy, and nursing collaborate and work inter-professionally to take care of a patient such as this in the “real world”. The schedule for the week will be provided during registration. Activities students will be involved in include:

• Presentations by various professional health care representatives • Working in the skills labs with hands on instruction such as learning to check vital signs, administer basic

medication including subcutaneous injection, priming IV tubing, using a glucometer, discovering the basics of a physical exam, and using lift equipment, etc.

• Participation in simulations in the patient simulation lab • Touring Life Flight (permission pending) • Analyzing blood for drug toxic levels • Compounding medications • Learning to walk with crutches or walkers • Understanding wheelchair mobility and practicing on Belmont’s campus • Gaining knowledge of balance and exercise skills • Learning about bedside care and rehabilitation • Day trips to charitable health clinics, long-term care facilities, and the Nashville Zoo

Damages Please be aware that each student is personally responsible for damages to any facilities including, but not limited to, the classrooms and laboratories they will be utilizing. Students will be asked to pay for any damages they cause. Facility information Belmont University Main Number: (615) 460-6000 Belmont University Website: www.belmont.edu Amenities: Corner Court (convenience store), McAllister's Express Deli, “We Proudly Brew” Starbucks location, Sandella's Sandwiches & Wraps, and other local restaurants

HEALTH SCIENCES SUMMER DAY CAMP APPLICATION FORM Please carefully and thoughtfully complete your application. Admission is competitive due to the popularity of the camps.

Name (Last, First, Middle Initial)

Email Address

Current mailing address (street or P.O. Box, apartment number, city, state, ZIP code)

Daytime phone number

Birthdate (MM/DD/YY) _____/_____/_____

Gender (circle one)

M F High School Ethnicity

□ Caucasian/White □ African American □ Hispanic/Latino American □ Asian American □ American Indian/Alaskan Native □ Native Hawaiian/Pacific Islander □ Other __________________________

Expected High School Graduation Year Cumulative High School GPA

Science Courses Completed 1. 2. 3. 4.

Planned Senior Year Science Courses 1. 2. 3. 4.

High School Honors and Awards

High School Extra-curricular Activities

Work Experience

In your own words, please respond to the following questions: Why are you interested in a career in a health science profession? What field(s) in health care have you considered? What steps have you taken so far to learn about the field? (Attach additional sheets as needed)

HEALTH SCIENCES SUMMER DAY CAMP RELEASE FORM

Bring ONE notarized copy of this document to registration and keep a photocopy for yourself to have with you in case of emergency at camp. Please attach a photocopy of your insurance card. Health Sciences Summer Day Camp Venue: Belmont University – Nashville, TN CAMPER INFORMATION

Name (Last, First, Middle Initial) Age Birthdate (MM/DD/YY) ____/____/____

Grade Completed (campers only)

Current mailing address (street or P.O. Box, apartment number, city, state, ZIP code)

EMERGENCY CONTACT INFORMATION

In case of an emergency, please notify: Relationship to camper

Mobile ( ) Home ( ) Work ( )

MEDICAL PROFILE

Generally, the participant’s health is (check only one): □ Excellent □ Good □ Fair □ Poor

If “Fair” or “Poor”, please explain the condition:

List any medical difficulties which are currently being treated:

Check any of the following that cause you problems and explain: □ Asthma □ Sinusitis □ Bronchitis □ Kidney Trouble □ Heart Trouble □ Diabetes □ Dizziness □ Stomach Upset □ Hay Fever

List any medicines or substances to which the camper is allergic:

List any previous operations or serious illnesses:

List any medications you are currently taking: Date of Tetanus Immunization: ___/___/____

Childhood Diseases: □ Chickenpox □ Measles □ Mumps □ Whooping Cough □ Other:

List any special diet or special needs:

Family Physician Physician Phone ( )

Insurance Company Subscriber name

Policy #

Subscriber #

Employer Subscriber Occupation

PERMISSION FOR MEDICAL TREATMENT, PHOTOGRAPH/VIDEO NOTICE, AND RELEASE AND INDEMNITY

I sign this informed consent and release agreement in consideration of my child’s participant in the Health Sciences Camp, June 15-19, 2015. My permission is granted for the camp or event director, any camp or event staffer, or adult present or in charge of first aid, to obtain necessary medical attention in case of sickness or injury to me or my child. I agree to be responsible for any costs incurred related to medical services for me or my child. Program staffs are trained and as a team committed to your rewarding experience with safety as their highest priority. However there are inherent risks to participation in recreation activities, including but not limited to, initiative activities, high and low challenge courses, outdoor education, and transportation to and from activities. Participants could experience any of the following – elevated heart and respiratory rates, uncomfortable group dynamics, climbing or descending, unpredictable and possibly slick or uneven terrain, jumping, running, climbing, carrying weight on your backs and shoulders, unforeseen forces of nature or weather, traffic accidents, and other incidents, any of which could result in injury/illness that could result in loss of life, limb, and/or property. I confirm that my child is in good health and physically capable of participating in these activities. I recognize there are risks and hazards involved in these activities that could result in injuries. With full knowledge of the facts and circumstances surrounding these activities, I voluntarily agree to assume all the risks and responsibilities of my child’s participation in them. Also, I understand that I or my child may be photographed or videotaped during normal camp or event activities, and these photos/videos may be used in Belmont University promotional materials, including broadcast over the Internet. In addition, I, on behalf of myself, my child, family, heirs, and legal representatives, release, waive, and forever discharge Belmont University, its agents, employees, officers, and governing board from and against any and all liability, claims, and actions that may arise from injury or harm to my child in connection with these activities. I represent and acknowledge that I have completely read and understand this document and all its terms and all matters referred to herein, and I signed voluntarily as my free act and deed, that I have had an ample opportunity to obtain the advice of counsel and that, by signing this document, I understand that I am relinquishing legal rights and remedies that may have otherwise been available to me. I understand that this consent and release shall be construed as broadly and inclusively as is permitted by applicable law and agree that if any portion of this document is held invalid, the remaining portions shall continue in full force and effect. Copy to Camp Venue. It is understood and agreed that a copy of this form shall be treated as authentic and binding as the original and that a copy of same shall be provided to camp venue. Complete and sign below (participants who are minors per your state statute require Parent/Legal Guardian signature). Participant’s Signature (only if 18 yrs of age or older): __________________________________ Date: ____________ Parent/Guardian Signature: ___________________________________ Phone: _______________ Date: ____________ Notary Acknowledgement: State of ________________ County of _______________________ On _______________________ before me, _______________________, Notary Public, personally appeared _________________________________________ who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the state that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Notary signature: ____________________________ My commission expires:_________________

SPECIAL ATTENTION CARD CAMP LOCATION: ___________________________________ CAMP DATES: ______________________ STUDENT NAME: ____________________________________ AGE: ____________________________ DESCRIPTION OF NEED: (use space below as needed) Please provide information that will help us to better mentor this student. DO NOT disclose any confidential information.

FOR HEALTH SCIENCES SUMMER DAY CAMP STAFF USE ONLY

Provide details of ways you mentored specifically to this student. Provide any changes noted or actions taken on the part of the student. Provide comments to parent about this student. STAFF SIGNATURE: ________________________________ DATE: __________________