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TO BE COMPLETED BY PROGRAM STAFF:

Program/Event Name: ___

Date(s):___ County/Location: ___

Employee Name: _____ Program Area: _____

Participant Information

Participant Name: ___ Date of Birth: ___

Parent/Guardian Name: ___

Telephone:_____

Email: ___

1. RESPECT FOR OTHERS AND PROPERTY.

Do not touch or remove any items that do not belong to you.

Do not use profanity or any other inappropriate language while participating in the program.

- Display an attitude that is always respectful of self and others.

2. RESPECT AND FOLLOW THE DIRECTIONS OF THE STAFF AND VOLUNTEERS

Follow the instructions of the Camp staff and other recognized authority figures at the University.

Be in assigned dorm room and in bed at the designated time.

Listen quietly and attentively to speakers and others during scheduled activities.

Conduct oneself in a manner that demonstrates an interest in learning while participating in scheduled activities.

3. PARTICIPATION AND RESPONSIBILITY

Report to the scheduled activities on time and remain there until instructed otherwise by an appropriate university employee.

Actively participate in all program and recreational activities.

Assist in clean-up of living quarters (if applicable), common areas, and instructional/work site space.

4. TECHNOLOGY AND CELL PHONE USE

Cell phones are prohibited during meals, classes, presentations, workshops, and other program events requiring full attention and participation.

Use of computers, tablets, and other technology must follow University IT policy.

Appropriate use of technology:

Do not intentionally damage equipment, software, or data belonging to KSU or other users.

Do not intentionally introduce destructive software (e.g., a virus) or circumvent system security measures.

Do not use KSU computers or equipment for viewing or distributing obscene materials, or for abusing, harassing, threatening, or discriminating against others.

o Do not make unauthorized copies of licensed software.

Do not use University equipment in any manner that violates instructed or recommended use by a supervising adult.

Do not use accounts, codes, or passwords without authorization or share them with unauthorized individuals.

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PARTICIPANT NAME: ___

5. ALCOHOL, DRUGS, AND TOBACCO

Detection of a violation will result in immediate dismissal from the program.

Do not improperly use prescription or non-prescription drugs.

• Follow the Medication Administration Procedure for the camp or program (as applicable).

Do not possess, distribute, or consume alcohol, illegal drugs/controlled substances

Do not display a alcohol-related or drug paraphernalia.

Do not use tobacco products.

6. SAFETY AND BEHAVIOR GUIDELINES

- Listen attentively to safety guidelines as instructed by staff, facilities, and offsite partnering organizations.

Do not engage in behavior that has the potential or is intended to harass, intimidate, or deter another person from participating or benefiting from the camp activities.

No bullying and hazing are strictly prohibited. Do not engage in reckless or intentional act toward another person that may cause humiliation, embarrassment, or ridicule, or physical, mental, or emotional discomfort

Do not cause or assist in misuse, vandalization, defacement, disfiguration, or destruction of property belonging to others, the University, or a partnering organization.

Participants and parents/guardians should be aware that all program/camp activities conducted on the campus of Kentucky State University are subject to applicable University policies and procedures.

For additional information, please visit the Kentucky State University Policy Library or scan the QR code below:

Participant Signature _____ Date _____

Date ___

Parent/Guardian Signature ___ Date ___

Date