APPLICATION INFORMATION FOR STUDENT

Friday, February 3, 2012

8:00 a.m. – 3:00 p.m.

Location:  Cape Girardeau Career and Technology Center

1080 S. Silver Springs Rd., Cape Girardeau, MO  573-334-0826

The Rotary Camp Enterprise Summit is a fun, learning opportunity for juniors and seniors from twenty southeast Missouri high schools.  Seventy students will be chosen from applicants to attend.  Senior applicants will get priority placement.  Area Rotary Clubs and business sponsorships make it possible to provide this event at no cost to students.  Meals, drinks and materials are provided free.

Rotary Camp Enterprise Summit participants will be dismissed from classes all day on Friday, February 3, 2012 – 8:00 a.m. until 3:00 p.m.

 Four $500.00 scholarships will be awarded to students who complete the summit!

 Get more information about the Summit at www.campenterprise.info

 ➣          In order for students to be considered for acceptance,

    this entire application form must be completely filled out.

Please do not submit an application if you are unable to attend for the full day.  Since space is limited to 70 students, your serious commitment to attending is important.

 Senior applicants will have top priority since it will be their last chance to attend.

 Transportation to and from the event will be arranged if necessary.  Note on Page 2 of the application if you need this service.

Students attending the Rotary Camp Enterprise Summit will experience first hand activities designed to focus on the free enterprise system and entrepreneurial processes.  Rotarians and other community leaders will serve as mentors and facilitators in this student-driven event.

 REGISTRATION:  Please fill out the application and submit to your school guidance counselor by January 12^th.  Guidance counselors will submit all applications no later than January 16^th  to the committee.  Students will receive acceptance letters by January 26^th with additional information.

*Please retain this page for information.

 NAME:__________________________________NAME ON TAG:________________________

 CIRCLE ONE:   Male     Female       CIRCLE T-SHIRT SIZE:   S   M   L   XL   XXL   3XL

GRADE LEVEL (CIRCLE ONE):           JUNIOR         OR        SENIOR

 ADDRESS:      _________________________________________________________

                    _________________________STATE _______ ZIP CODE__________

 PHONE NUMBER:  ( ___  ___  ___ )   ___   ___  ___  -  ___  ___  ___  ___

 PARENT/GUARDIAN NAME:  _____________________________________________

 PARENT BUSINESS PHONE/CELL:  ( ___ ___ ___ )  ___ ___ ___ - ___ ___ ___ ___

 SCHOOL:  ____________________________________________________________

 STUDENT INFORMATION: (Please use the back if you need more room)

School Activities:

Other Activities (Scouting, Church, Community, etc.):

Awards, Recognitions:

Employment:

Career Objectives:

Check one:  I need transportation ____   I do not need transportation ____

To be filled out by school officials

SCHOOL COUNSELOR / OFFICIAL_____________________________________

______I recommend this student for the Camp Enterprise Summit .

__________________________________________________________________ Signature/Date

Please submit all applications no later than January 16, 2010 to the address below.

Fax Application To: 573-243-8723 Or

Mail to: Rotary Camp Enterprise Summit

c/o:   Jackson Rotary Club

P.O. Box 414

Jackson, MO  63755

For information call:  Brigitte Bollerslev at 573-382-0416 or e-mail bb@hrb-consulting.com

Rotary Enterprise Summit

Medical Consent/Release

I/we consent to the participation of our child/ward, ______________________, in the Rotary Camp Enterprise Summit.  Our child has no health conditions that would limit participation in camp activities or any other physical condition except as stated below.

Medications:           _________________________________________________________

 ____________________________________________________________________

Frequency taken:    ___________________________________________________

Allergies:      _________________________________________________________ 

General Physical Condition:         ________________________________________

Physician: _______________________ Phone: ( _  _   _ ) _  _  _ - _  _  _  _

Emergency Contact:  _______________________ Relationship: ______­­­­­­_____­­­­­­­­­­­­­­­____

Phone-Business/Cell: ( _  _  _ ) _  _  _ - _  _  _  _ Home: ( _  _  _ ) _  _  _ - _  _  _  _

Authorization to Provide or Obtain Emergency Treatment

 I/we hereby authorize personnel of Rotary Enterprise Summit to provide, or act on my behalf to obtain any medical, dental, or surgical treatment for the above-named student, if such personnel believe such treatment is necessary for any reasons.

In consideration of THE ROTARY CLUBS’ selection of your child/ward to participate in the Camp Enterprise Summit, the education, fellowship, and recreation that will be provided to them, I/we hereby release and forever discharge Rotary, its members and employees, from any claim(s) for injuries sustained by your child/ward in connection with or arising out of their participation, unless such injuries are caused by the negligence or willful or wanton misconduct of Rotary, its members or employees.  I/we further agree to indemnify Rotary, its members and employees and hold harmless from any liability, loss or damage as a result of claims, demands, lawsuits or judgments made or asserted against them by our child or by anyone on his or her behalf.

Signed (Parent/Guardian):______________________________ Dated:__________