Register and Permission Form

Student's Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Email(Required)

School(Required)

Age(Required)

Grade(Required)

Gender(Required)

Preferred Pronoun(Required)

Race(Required)

County(Required)

T-shirt Size

Social Media (active on)(Required)

Facebook

Instagram

Twitter

SnapChat

TikTok

Interests and Hobbies(Required)

Parent/Guardian's Name(Required)

First Last

Parent/Guardian's Email(Required)

Parent/Guardian's Phone(Required)

Why would you like to be in the Resilient Teen Program? Write a short essay - 300 words maximum.(Required)

Photo Permission(Required)

Yes

I also give my permission for my child's picture to be used in the Resilient Teen Project final report.

Parent Signature(Required)

I expressly release Augusta University or Georgia Family Connection from any liability arising in any way from my child’s participation in this volunteer project. You may revoke this permission at any time in writing.

Student Signature(Required)

Code of Conduct

Student Name

Parent/Guardian Name

Program/Activity Name: MCG-AU Pediatric Pathways Program Pilot: An Innovative Approach to the Pediatric Standardized Patient

This Code of Conduct is to ensure the safety and well-being of all participants in a Program/Activity hosted at or by Augusta University. It applies to all participants including minors and their parents/guardians.

Requirements:

Respect and adhere to Program/Activity rules and guidelines including all those specific to this event or activity.
Follow all instructions and directives given by Program/Activity Staff.
Act in a courteous manner and treat participants, parents, volunteers, staff, and others with respect. Appropriate language and behavior are expected at all times.
Uphold an individual’s right to dignity by supporting an environment of inclusion which welcomes involvement of participants from all backgrounds.
Obey University policies and local, state and federal laws.

Participants who fail to adhere to this Code of Conduct are subject to a range of disciplinary actions. When appropriate, immediate corrective action will be taken to ensure the safety and welfare of all participants. Failing to adhere to this Code of Conduct may subject participants to disciplinary action, up to and including removal from the Program/Activity and future Programs/Activities offered at Augusta University.

PARTICIPANT ACKNOWLEDGEMENT AND AGREEMENT

I understand that as a condition for participating in the Program/Activity I must comply with the Program/Activity’s rules and standards of conduct and follow all reasonable direction of the Program/Activity Staff. Failure to comply with the Program/Activity’s rules and standards of conduct or failure to comply with the reasonable direction of Program/Activity Staff may result in my being dismissed from the Program/Activity and impact my ability to participate in future Programs/Activities.

Date

PARENT/GUARDIAN ACKNOWLEDGEMENT AND AGREEMENT

I understand that my child will be subject to the rules and standards of conduct of the Program/Activity and the University System of Georgia. I further understand that my child’s violation of the rules and standards of conduct or failure to comply with the reasonable direction of Program/Activity Staff may result in my child’s dismissal from the Program/Activity. I accept responsibility for all costs associated with removing my child from the Program/Activity, including but not limited to transportation costs to return my child home. I understand that dismissed Participants are not eligible for a refund of any fees or expenses and may not be eligible to participate in future Program/Activities.

Date

Register & Permission

Code of Conduct