Glenville State College

June 23 (Monday) – June 27 (Friday)

Mail this application to:

Department of Social Science * Glenville State College * 200 High Street * Glenville, WV 26351 * ATTN: Dan Martens M.S. Criminal Justice Camp

First Name ___________________ M.I. ____ Last Name ______________________ Name tag Name _____________

Mailing Address ___________________________________ City _______________________ State ____ Zip _______________

Home Phone (_____) _______________________ E-mail Address _______________________________ Grade Next Fall ____

Age _____ Birthdate (mm/dd/yyyy) ___________________ Male ____ Female ____

Current School ______________________________________________

Student Sponsor* _______________________________________________ Sponsor’s Position __________________________

The GSC Criminal Justice Camp does not tolerate cases of vandalism, fighting, substance abuse, or other violations of camp and University safety regulations. No refunds are given for cases of expulsion from camp. The camp reserves the right to expel a student on these or any other grounds.

Mother’s name ______________________________ Mother’s day phone ____________________ Night phone ______________

Father’s name _______________________________ Father’s day phone _____________________ Night phone ______________

Alternative Emergency Contact Name(s) & Phone Number(s)___________________________________________________________

What is your current GPA (on 4.0 scale)? __________

List your extracurricular activities:

______________________________________________________________________________________________________________________________________________________________________________________________________________________

Have you ever taken a criminal justice class before? Yes__________ No ___________

If yes, please state what classes you have taken and when: ______________________________________________________________________________________________________________________________________________________________________________________________________________________

Are you graduating and attending college in Fall 2008? Yes __________ No____________

Have you applied to Glenville State College? Yes __________ No ____________

Each student is required to obtain a sponsor endorsement, or recommendation letter, to attend camp. This can be provided by a principal, vice-principal, counselor, or criminal justice instructor.

Sponsor _______________________________________________ Sponsor’s Position ___________________________

Brief Statement indicating why/how this student would benefit from attending the camp.

Sponsor’s Signature _________________________________________________ Date ________________________________

Sponsor’s Telephone # ___________________________________________ Email ___________________________________

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Glenville State College

Criminal Justice Camp 2008

Mother’s name ______________________________ Mother’s day phone ____________________ Night phone ______________

Father’s name _______________________________ Father’s day phone _____________________ Night phone ______________

Alternative Emergency Contact Name(s) & Phone Number(s) ___________________________________________________

I, the undersigned, as the parent or legal guardian of ___________________________________ (a minor), hereby authorize such diagnostic, medical and/or surgical treatment of a minor as may be considered necessary or appropriate under the circumstance for the treatment of any illness or injury of the minor. I hereby release and otherwise hold harmless the attending physician, appropriate staff, and Glenville State College and its officers, regents and employees from legal liability or any consequences from said diagnostic, medical, and/or surgical treatment, and thereby released from any and all claims and causes of action that may arise, grow out of, or be incident to such diagnosis, treatment, or surgery insofar as the law allows and provides that these services are performed with ordinary care and the best of their ability.

Parent/legal guardian signature ____________________________________________________________________________

Print name ________________________________________________ Date ________________________________________

Allergies ______________________________________________________________________________________________

Current Medications _____________________________________________________________________________________

Date of last Tetanus booster _______________________________________________________________________________

I, the undersigned, as the parent or legal guardian of the minor child, hereby acknowledge that the forenamed minor is covered by medical and prescription drug coverage as follows:

Name of Insured_____________________________________ Name of Insured _____________________________________

Insurance Company __________________________________ Insurance Company __________________________________

Phone______________________________________________ Phone ____________________________________________

Employer/Group name ________________________________ Employer/Group name _______________________________

Group number ______________________________________ Group number ______________________________________

ID #_______________________________________________ ID # ______________________________________________

It is further understood that Glenville State College does not provide medical insurance covering injuries any nature incurred at the 2008 Criminal Justice Camp. The undersigned hereby releases Glenville State College, its successors, assignees, officers, agents, and employees from any and all claims, demands and causes whatsoever in any way growing out of or resulting from participation of the released parties in the 2008 Criminal Justice Camp, except for claims caused by the gross negligence of the released parties. I understand that Glenville State College is not liable for any accidents, medical charges, emergency room charges, or medications or pharmaceutical charges incurred during the 2008 Criminal Justice Camp.

Parent/legal guardian Signature _____________________________________________________ Date __________________

Please mail this medical release form to:

Department of Social Science * Glenville State College * 200 High Street * Glenville, WV 26351 * ATTN: Dan Martens M.S. Criminal Justice Camp

June 22 (Sunday) – June 28 (Saturday)