2023 GEAR UP Summer Camp
Application must be completed in full online or postmarked by April 28th, 2023. There are a limited number of spots per target school and they are reserved on a first come first serve basis.
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Email *
Session offered: *
Required
Student Last Name: *
Student First Name: *
Student Middle Name:
Student School Email Address *
Parent Email Address *
Mailing Address (number and street name): *
 City: *
State: *
Zip code: *
Phone Number *
Birth date (mm/dd/yyyy): *
Grade (2022-2023): *
Preferred pronouns:  *
Gender: *
School: *
Racial/Ethnic Background: *
Are you a student with a disability?  Yes or No. If yes, specify. *
Medical Conditions  *
Required
If yes to any of the above medical conditions, please specify. If no to any of the above medical conditions, please write none.  *
Do you have any dietary restrictions? (i.e. Halal, Kosher, Vegan, Vegetarian, etc) If yes, Please specify  *

By signing this form, I verify that my child, the above named student on this application, is in good health upon attending the MI GEAR UP Program at Western Michigan University.

I do hereby authorize my dependent, the above named student on this application, to receive medical examinations and emergency treatment by a licensed physician, if necessary, while participating as a student in the Western Michigan University MI GEAR UP summer programs. However, I fully understand that MI GEAR UP does not pay for medical services received by my dependent during his/her campus experience. I also understand that such bills will be forwarded to me for payment. I also understand that the MI GEAR UP staff will not perform any medical procedures or administer any medicines to my student including aspirin.

●     If your child requires an inhaler, the child must bring it with them to campus, and he/she must keep it with them at all times.

●     If your child is diabetic, all required medication should be with the child at the time of arrival. If he/she requires insulin shots, they must be able to administer it themselves.

If your child requires an EpiPen, the child must bring it with them to campus, and he/she must keep it with them at all times. 

Please write your name and today's date. This will serve as your electronic signature.
 *
The above named student is covered by: *
If your child is covered by health insurance, please provide the following information: Insurance company, Individual policy holder's name, Contact number, Group.
Guardian will need to sign and date. 

If no health insurance, please just sign and date. 

Please write your name and today's date. This will serve as your electronic signature.

 *
Emergency Contact Information
Please complete all information for Emergency Contacts 
Guardian 1   Name, Relationship, Phone Number  *
Guardian 2   Name, Relationship, Phone Number  *
In an emergency, if we could not contact you, who else could we contact? 
Alternate Contact 1: Please include name, relationship, and phone number *
Alternate Contact 2: Please include name, relationship, and phone number *

My child/dependent, the above named student on this application, is authorized to travel on MI GEAR UP sponsored trips and affairs in vehicles and other modes of transportation provided by the MI GEAR UP Program while a participant in the summer programs.

Please check the appropriate boxes below to indicate your student’s transportation needs:

 *
Required

Programs serving pre-college youth on campus are required to follow the same WMU COVID policy as the rest of the University.  Thus youth participating in summer camps must follow WMU's Covid policy.  WMU's policy is reviewed regularly and updated as needed based on information from the State of Michigan or the CDC.  If WMU were to update its policy prior to or during the MI GEAR UP summer program, participants would have to follow the current and most updated COVID policy.  Currently, WMU is no longer requiring vaccine verification, required testing, or masks.  Current WMU COVID policy can be found at: https://wmich.edu/covid-19.

 

Visitor Guidelines

To ensure the health and safety of you and the Western Michigan University community, we have implemented the following measures based on public health directives from the State of Michigan and the Center for Disease Control:

Before your visit

●     Check for COVID-19 Symptoms: Please perform a COVID-19 symptom assessment before arriving on campus and stay home if you do not feel well or if you have been in contact with someone who has contracted COVID-19.

●     Face Coverings: Face coverings are optional as of May 6th in WMU facilities.

●     We will follow social distancing guidelines during your visit and ask that you do the same.

●     Each day pre-college youth are present on campus they must complete a health screening.

Please write your name and today's date. This will serve as your electronic signature.

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I, being the Parent/Guardian of the above named student on this application, herby consent that the MI GEAR UP Program at Western Michigan University may take photographs, video, and/or electronic images of my child throughout the summer programs. I further consent that such photographs, films, recordings, electronic images and the film, slides, disks, or tapes from which they are made shall be the property of the MI GEAR UP Program at Western Michigan University, and they shall have the right to duplicate, reproduce and make other uses of such photographs, films, records, and tapes for documentation and promotional purposes.

 *
Please write your name and today's date. This will serve as your electronic signature. 
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