Urban University

Urban University Summer Camp 2019
June 3 - July 13 | 10am - 4pm

Urban University Summer Camp is a six-week, high impact summer program, to prevent summer learning loss and equip youth with the intellectual, social, and creative resources necessary for academic, career, and life success. Sessions include classes on:

Health/Wellness
Leadership
STEM
Entrepreneurship
College/Career Readiness
Arts/Humanities

If you are interested, fill out the registration form below or contact us @ (512) 428-4480 x209 or email lhernandez@aayhf.org for more information!

*In order to ensure enrollment, you must submit a complete application. A complete application is one that has ALL fields completed, as well as the $30 activity fee (per student), payable via the DONATE page or in person.

Registration for Urban University is now open!

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Order Number

Urban University 2019 Application

Below is the application for Urban University 2019! Some things have changed and in order to ensure we provide high quality programming, we are limiting the number of students in the summer camp to 125. Your application will be accepted, however, spots are reserved on a first-pay basis. After your application is complete please pay the $30 activity fee (per student) through our donations page or in person at our office.

Please make sure all areas are fully completed. Thank you!

Did this student attend Urban University 2018?

Email Address:

How many students are you registering?

Phone:

Student Name:

Age

Date:

Address:

City

Zip Code:

Education

What school are you currently enrolled in?

Grade:

2017-2018 Grades

Please submit a copy of your student's most recent grade report. We use this for program quality evaluation and performance metrics.

2018-19 Grade Report

Emergency Contact Numbers:

If someone else will be signing the student in or out please provide their information as alternate. emergency contact will be contacted if neither the alternate or parent can be reached.

Parent/Guardian Name:

Parent/Guardian Phone #:

Cell #:

Email:

Alternate Name:

Alternate Phone #:

Person to contact if parent/guardian cannot be reached:

emergency contact phone #:

emergency contact relationship:

Family Physician:

Physician Phone #:

Hospital preference:

EEO Data (the following is requested for record keeping)

Ethnic Origin

Gender

How many in household?

I understand that if I am selected, it will be at the discretion of the African American Youth Harvest Foundation. I further understand that participation in this program is a privilege, and that any level of misconduct against other program participants or program staff will result in immediate termination/loss of privilege to continue in this program. I certify that I have made no misrepresentation in this application and I have not withheld information in my statements and answers to questions. I hereby authorize the African American Youth Harvest Foundation to investigate and verify and representations made by me, either orally or in writing. I hereby release the AAYHF, and any individual who provides or obtains, information pursuant to this authorization, from any and all liability for damages of any kind.

I agree

Release of Liability

1.This form releases liability from the AAY Harvest Foundation Inc. (AAYHF) and the AAYHF –Related Parties for the purpose of educational activities and travel to and from outlined activities. The Participant(PAR) or the person signing on behalf of the (PAR) releases and discharges AAYHF, and any of itsdirectors, officers, board, employees, partners, affiliates, successors, assigns, agents and volunteers(collectively, the AAYHF –Related Parties) from any liability or responsibility for any accident or injury to person or property which may occur during the course of such educational activities and travel, except for liability or responsibility resulting from the gross negligence or willful misconduct of the AAYHF-Related Party claiming release. In the event of any accident or injury to person or property which may occur during such educational activities and travel, AAYHF-Related Parties will contact the person designated as the emergency contact on the initial application form on file unless otherwise directed by the PAR on this form.

2.The PAR or the person signing on behalf of the (PAR) hereby agrees to indemnify and hold harmless the AAYHF-Related Parties from and against any damage, claim, loss, liability or expense occurred in connection with or arising out of any accident or injury to person or property which may occur during such educational activities and travel, except for any damage, claim, loss, liability or expense resulting from the gross negligence or willful misconduct of the AAYHF-Related Party seeking indemnity.

3.The person signing this Release on behalf of the PAR and on behalf of AAYHF each represents that s/he is duly authorized to do so.

By signing below I agree to the terms stated above.

Electronic Signature of Student

Electronic Signature of Parent/Guardian

Date:

Date:

Field Trip Participation, Media Release & Medical Information

Student Name:

Field Trip Permission

As part of the Urban university Summer Camp experience your child will be going on 3-4 field trips. By checking the box below and signing this page at the bottom, you consent to the above signed students to participate in the field trips.

Consent

I hereby give permission for the students named above to participate in AAYHF field trips as stated above.

Are there any specific issues that your child is experiencing that you would like us to know about? (ex. depression, anger issues, home issues, recent divorce, violent)

Yes

No

If yes, please explain:

Date:

PLEASE READ AND INITIAL (CHECK) ALL POINTS

I give permission for my child to receive services provided, including but not limited to supportive guidance/counseling, tutoring, enrichment activities, testing, and referrals to other agencies as needed.

I give permission to the program to transport my child in agency vans and/or staff-operated vehicles to and from our after-school site on special field trips. I hereby release participating agencies and/or the operator of the vehicle being used from any responsibility and liability for any damage, injury or illness which might occur during, or resulting from, the authorized transporting of my child.

I understand and agree that neither the program nor its employees and volunteers are responsible or legally liable for any personal property losses or for any bodily injuries incurred and suffered by the child on any program property or in connection with any program activities.

I understand that my child must adhere to all AAYRC rules and regulations in order to remain in the program.

I understand that the records and information released under this consent will be kept confidential to the extent permitted by law and will be used for the purpose indicated.

I understand that this consent is voluntary.

Photo/Video Release

I will allow my child to be photographed and/or video taped while engaged in program activities and for those images to be used for publicity and/or recruitment purposes.

Yes

No

Medical Information & Release

In the event of illness or injury, I do hereby consent to whatever emergency medical treatment may be deemed necessary for my child. I further understand and agree that any medical treatment will be provided at my expense (or that of my insurer) and that neither the AAYHF nor its affiliates will be responsible or liable for costs and fees related to such medical treatment.

Insurance Carrier

Policy Number

Telephone Number

Are there any medical conditions and/or medication that should be known to staff or emergency medical providers in the event of accident or injury?

Waiver & Release

I/we acknowledge that, as a condition of my child participating in the above-described activity, I/we hereby hold harmless, and waive and release, AAYHF (the “Summer Camp”), the AAYHF affiliate organizations and the respective officers, agents, employees and contractors of each of them (“Releases”), from and against any and all actions, claims, demands, liabilities or expenses that I/we now have or may hereafter have relating to any injury, accident, illness, death, and/or any loss or damage to personal property occurring during, or resulting from my/our child/ward’s participation in the above-described activity, including, but not limited to, claims arising out of any negligence of Releases, and each of them.

I/WE ACKNOWLEDGE THAT I/WE HAVE CAREFULLY READ THIS REQUEST FOR STUDENT PARTICIPATION IN FOUNDATION-SPONSORED ATHLETIC ACTIVITIES AND FULLY UNDERSTAND ITS TERMS. I/WE ARE AWARE THAT THIS DOCUMENT INCLUDES A WAIVER AND A RELEASE OF LIABILITY.

BY SIGNING BELOW, I/WE AGREE TO THE TERMS AND CONDITIONS AS STATED ABOVE AND AGREE TO PERMIT MY CHILD/WARD TO PARTICIPATE IN THE ABOVE-DESCRIBED ACTIVITY.

ALL INFORMATION IS COMPLETELY CONFIDENTIAL

I am the parent or legal guardian of minor named above and have legal authority to execute this consent and release.

E-Signature:

Date

Changing Lives,
Building Better Futures

Changing Lives,
Building Better Futures

Urban University Summer Camp 2019
June 3 - July 13 | 10am - 4pm

*In order to ensure enrollment, you must submit a complete application. A complete application is one that has ALL fields completed, as well as the $30 activity fee (per student), payable via the DONATE page or in person.

Registration for Urban University is now open!

Urban University 2019 Application

Education

2017-2018 Grades

Please submit a copy of your student's most recent grade report. We use this for program quality evaluation and performance metrics.

Emergency Contact Numbers:

If someone else will be signing the student in or out please provide their information as alternate. emergency contact will be contacted if neither the alternate or parent can be reached.

EEO Data (the following is requested for record keeping)

Release of Liability

Field Trip Participation, Media Release & Medical Information

Field Trip Permission

Photo/Video Release

Medical Information & Release

Waiver & Release

ALL INFORMATION IS COMPLETELY CONFIDENTIAL

Connect

Get Involved

Resources

Become a Sponsor

Changing Lives,Building Better Futures

Changing Lives,Building Better Futures

Urban University Summer Camp 2019June 3 - July 13 | 10am - 4pm

*In order to ensure enrollment, you must submit a complete application. A complete application is one that has ALL fields completed, as well as the $30 activity fee (per student), payable via the DONATE page or in person.

Registration for Urban University is now open!

Urban University 2019 Application

Education

2017-2018 Grades

Please submit a copy of your student's most recent grade report. We use this for program quality evaluation and performance metrics.

Emergency Contact Numbers:

If someone else will be signing the student in or out please provide their information as alternate. emergency contact will be contacted if neither the alternate or parent can be reached.

Connect

Get Involved

Resources

Become a Sponsor

Changing Lives,
Building Better Futures

Changing Lives,
Building Better Futures

Urban University Summer Camp 2019
June 3 - July 13 | 10am - 4pm