Summer Immersion Program Student Application

Overview

The Office of Pre-College Programs at the University of Mississippi hosts various programs for students in rising 1st through 12th grades. The Summer Programs Application is part of a three-step registration process for our summer immersion programs. This form is Step Two in the process and collects a student's information, contact details, and includes parent and guardian agreements for program rules and guidelines and the University of Mississippi's COVID Liability Waivers.

Please complete the following registration form and online form packet to register for our programs.

Registration Process

Summer registrations are a 3-step process (detailed below) - THIS IS STEP TWO! All steps are available from the program webpage.

STEP ONE: Pay and reserve seat in program.
STEP TWO: Complete the Program Student Application and required online forms.
STEP THREE: Complete and upload the student's Medical Form, copy of a parent/legal guardian's Driver's License, and copy of student's medical insurance card or Waiver of Medical Insurance Form (included in Medical Form packet).

Upon completing STEP TWO, you will receive an email requesting the student's Medical Form and supporting documents (listed below). It will also include a secure upload link.

Medical Form
Copy of a parent's Driver's License
Copy of student's insurance card OR Waiver of Medical Insurance Form

Important: Step Two and Three only have to be completed ONCE per summer. Additional program registrations will be connected to a student’s application.

Have you completed STEP ONE: Pay and Secure Spot?(Required)

Yes

STOP!

This online form is STEP TWO: Online App and Forms. If you have NOT completed Step One to pay and secure your spot in your selected program, please go back to the selected program page and complete Step One. If you completed Step One successfully, you should have received an Order Receipt via email. Completing the registration steps out of order may cause delays and errors in your registration process.

If you have any questions or concerns, please do not hesitate to reach out to our office at precollege@olemiss.edu

Program Registration Information

Program Level/Type(Required)

Select the program level(s) your student is participating.

Elementary Day Camps (rising 1st to 6th grades)

Middle School Day Camps (rising 5th to 7th grades)

Middle School Programs (rising 6th to 8th grades)

High School Programs (rising 9th to 12th grades)

Elementary Day Camps

Ecology Day Camp

Makers and Mechanisms

Rebel Quest

Middle School Day Camps

Makers and Mechanisms

Middle School Programs

Creative Writing

Discover Engineering at UM

Fantasy World Building

FIRST LEGO Robotics

Let's Build a Zoo

Rebel Chefs

High School Programs

Program Type(Required)

Select the program type that this student is participating. If participating in multiple program types, select "Residential."

Residential (stays overnight)

Commuter (checks-in/out each day)

Original Order Number(Required)

Enter the original six-digit order number from your Order Receipt, received via email after completing Step One. If multiple orders for the same student, please use only one Order Number.

Primary Contact Email(Required)

Please enter the email to which you would like to receive all email notifications related to this registration. Additional email addresses entered during registration may also receive communications from our office.

Enter Email Confirm Email

Student Information

Ole Miss Student ID Number (if applicable)

Please enter the student's Ole Miss ID number if applicable. If parent/guardian completing this form, please do NOT enter your ID number.

Student Name(Required)

First Middle Last Known By

Date of Birth(Required)

Gender(Required)

Female

Male

Non-binary

Gender

Race(Required)

Check any option(s) that apply.

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Pacific Islander

White

Other Race

I'd prefer not to answer

Race: Other

Ethnicity(Required)

Student Email

Please a non-school email address if available.

Student Cell Phone

T-shirt Size(Required)

Select the student's t-shirt size.

Dietary Restrictions

If applicable, please list any dietary restrictions or food allergies this student has.

Special Accommodations

Please list any special accommodations that the student needs.

Student Address Information

Country of Residence(Required)

United States of America

Other

State of Residency(Required)

Enter the U.S. state or territory in which you currently reside.

County or Parish of Residency(Required)

Enter the county or parish of the U.S. state/territory in which you reside.

Mailing Address(Required)

Mailing Address City State ZIP Code

Mailing Address(Required)

Mailing Address City State / Province / Region ZIP / Postal Code Country

Academic Information

Current Grade Level(Required)

Enter the student's current grade level as of Fall 2022.

Anticipated Senior (12th Grade) Graduation Year

Select the student's anticipated year of graduation from high school.

Current Grade Point Average

4.0 scale, if known

ACT Score

Highest composite score - if taken

SAT Score

Highest composite score - if taken

School Information

School Name(Required)

Enter the name of the student's high school. If homeschooled, enter "Homeschool"

School District

Enter the name of the school district, if applicable.

School City(Required)

Enter the city name for the high school.

School County/Parish(Required)

Enter the county or parish name for the high school.

School State/Territory(Required)

Enter the state or territory name for the high school. If not based in the U.S., select "International".

School Country(Required)

If the school is not based in the U.S., enter the country name in which the school if located.

Parent or Guardian 1 Information

Parent or Guardian 1 Name(Required)

Prefix First Last

Phone(Required)

Email(Required)

Relationship to Student(Required)

Is this parent/guardian (1) an emergency contact?(Required)

Yes

Does parent/guardian (1) work at the University of Mississippi?(Required)

Yes

Parent or Guardian 2 Information

Parent or Guardian 2 Name

Prefix First Last

Phone

Relationship to Student

Is this parent/guardian an emergency contact?

Yes

Does parent/guardian work at the University of Mississippi?

Yes

Emergency Contact Information

IN CASE OF EMERGENCY (when parent cannot be reached), please contact:

Emergency Contact Name(Required)

First Last

Cell Phone(Required)

Alternate Phone

Emergency Contact's Relationship to Student(Required)

Household Information

Did a parent or guardian graduate from a four-year college/university?

How many family members live in your household?

What is your household's combined income level?

Does this student have siblings?

If so, please list their names and ages. (Ex: John Smith, 10)

Does this student have any relatives who have attended the University of Mississippi?

None

Parent / Step-Parent / Guardian

Grandparent

Aunt / Uncle / Cousin

Sibling

Additional Information

Has this student participated in other programs at the University of Mississippi?

If yes, which programs and years has this student participated?

How did you hear about our program?

Other: How did you hear about our program?

Program Rules and Guidelines

The Office of Pre-College Programs hosts a wide variety of academic programs and day camps during the summer. All students participating in these programs are obliged to comply with the same rules and guidelines. Below is a list of guidelines for students participating in a summer program at the University of Mississippi. Specific dates, times, locations, and updated information will be emailed to parents and students at least one week prior to the session.

As you read through the guidelines and rules carefully, please check each statement agreeing to that section of the rules and certify by entering your signature below.

Medical Forms and Additional Paperwork

All participants (and their parents/guardian) are required to complete and return the listed items BEFORE a student is allowed to participate in a Pre-College Program’s summer program. Each item is linked on the camp or workshop webpage.

read and sign the following rules and guidelines,
complete a summer medical form,
complete the COVID compliance form, and
upload a copy of insurance card (front and back sides) and a parent/guardian’s drivers license

Medical Form(Required)

I understand that I am required to complete and sign the Medical Form.

Copy of a Parent or Guardian Driver's License(Required)

I understand that I am required to upload/submit a copy of a parent or guardian Driver's License or state-issued ID card.

Copy of Insurance Card or Waiver of Insurance Form(Required)

I understand that I am required to upload/submit a copy of a health insurance card covering the student or complete the Health Insurance Waiver included in the Medical Form packet.

Day Camp Programs Rules and Guidelines

Check-In

Daily drop-off is from 7:30 to 8:00 a.m. each day in Lamar Hall (for Rebel Quest and Makers and Mechanisms) and the University of Mississippi Field Station (for Ecology Day Camp). To ensure each students’ safety, an adult must walk the student into the building and sign the student in each morning. We strongly encourage students to arrive by 8:30 a.m. so they will not miss out on any scheduled activities.

On Monday morning, Pre-College Programs staff will check in students, verify the receipt of all required documents, give each student their camp bag and name tag, and direct students to their classroom.

Rebel Quest and Makers and Mechanisms: Please note that morning check in for all students will be at the back of Lamar Hall (entrance opposite of the Grove.

Ecology Day Camp: Check in for Ecology Day Camp students will be at the Education Building at the UM Field Station located at 15 County Road 202, Abbeville, MS.

Check-Out

Daily check-out is between 4:45 to 5:30 p.m. To ensure each students’ safety, an authorized adult must come to the student’s classroom and sign the student out each evening.

Check-In and Check-Out Information Acknowledgement and Agreement(Required)

I acknowledge and agree to the guidelines as outlined in Check-In and Check-Out Information.

Items Needed Everyday

Backpack or tote bag, sunscreen, and a thermos or refillable water bottle (we will have provide one if the student does not have one).

Lunch and Snacks

Rebel Quest: Students should bring their own lunch from Monday-Thursday. They will be provided two (2) snacks per day and lunch on Friday courtesy of Rebel Quest.

Ecology Day Camp: Students should bring their own lunch from Monday-Friday. They will be provided two (2) snacks per day courtesy of Ecology Day Camp.

Makers and Mechanisms: Students should bring their own lunch from Monday-Thursday. They will be provided two (2) snacks per day and lunch on Friday courtesy of Makers and Mechanisms.

Lunch and Snacks Information Acknowledgement and Agreement(Required)

I acknowledge and agree to the guidelines as outlined in Lunch and Snacks Information.

Clothing

Campers will be outside and active much of the time, so your child should wear comfortable, athletic, closed toe shoes (no Crocs, sandals, or flip flops) and casual outfits that are appropriate for outdoor play. Girls should avoid wearing dresses if possible. We want our campers to be cool and comfortable while participating in outdoor activities.

Clothing Information Acknowledgement and Agreement(Required)

I acknowledge and agree to the guidelines as outlined in Clothing Information.

Medications

If your child suffers from an allergy or any other condition, please make sure that they have their medication with them at all times and communicate any medical needs or concerns with the Rebel Quest teachers and counselors. Please note that Pre-College Programs staff, teachers, and counselors cannot administer any medicine, even over the counter medicine, to students.

Medications Information Acknowledgement and Agreement(Required)

I acknowledge and agree to the guidelines as outlined in Medications Information.

More Information

You will receive an email the week before each session of the day camp(s) for which the student is registered. The email will include the above information, details about special activities and field trips for the week, and any instructions related to the theme for the week.

Program Rules

Students will be expected to follow all rules set by their camp teacher and counselors. As rules and expectations will change based on the activity that the students are engaging in, students will be given clear instructions and expectations before and during each activity (i.e. crossing the road, playing in the Grove, working on a class activity, and swimming will all have different rules and expectations associated with them).

Program Rules Acknowledgement and Agreement(Required)

I acknowledge and agree to the rules as outlined in Program Rules.

Consequences for Rule Violations

If a student repeatedly breaks these rules and therefore hinders the experience and safety of themselves and/or other students, they will be referred to the program coordinator. Referral to the coordinator the first time will result in a parent conference with the coordinator. Referral to the coordinator a second time will result in dismissal from the remainder of the week. Please note that all fees are non-refundable if a student is dismissed based on rule violations.

Excessive and Severe Violations

Note that excessive or severe rule violations are not tolerated and are grounds for immediate dismissal from the program. Excessive or severe rule violations may include violent conduct, bad language, bullying, disrespect, fighting, hitting, spitting, biting, or any conduct that violates The University of Mississippi Creed.

Consequences for Rule Violations Acknowledgement and Agreement(Required)

I acknowledge and agree to the policy as outlined in Consequences for Rule Violations.

Summer Immersion Programs Rules and Guidelines

Check-In, Move-In, and Orientation

Residential: Check-In will be held in Hefley Hall, starting at 3:00 pm CST. Upon registration, students will move into their assigned residence hall. Students should be checked-in and moved into their room by no later than 4:30 pm CST.

Following move-in, there will be an orientation for students and parents at 5:00 pm CST. Attendance is mandatory for students and encouraged for parents. After orientation, parents are dismissed and students will be given directions about evening activities and welcome dinner.

Commuter: Orientation is mandatory for all students. Commuter students will check-in at the orientation location and will be dismissed at the end of orientation. Commuter check-in will be available at 4:30 pm CST.

Check-In, Move-In, and Orientation Acknowledgement and Agreement(Required)

I acknowledge and agree to the guidelines as outlined in Check-In, Move-In, and Orientation.

Overview of Activities During the Program

The purpose of all sessions and camps is to introduce students to future career options, college life, and enriching summer activities. Daily schedules are filled with morning and afternoon classes, tours of facilities, team-building activities, and more. There are a wide variety of activities planned for students that include sports tournaments, cultural engagement, and recreational activities.

Attendance at Activities: For students to benefit from the college experience, all students are expected to attend all activities and all class sessions.

Residential students will be given the choice to attend some evening activities, but community activities are mandatory every evening.
Commuter students will be dismissed after class is over each day.

Overview of Activities During the Program Acknowledgement and Agreement(Required)

I acknowledge and agree to the guidelines as outlined in Overview of Activities During the Program.

What to Bring

Residential students

should bring linens for an extra-long twin bed, personal hygiene items and toiletries (shampoo, towels, etc.), shower shoes (flip flops), and cleaning supplies. We also suggest students pack comfortable summer clothes and sportswear such as swimsuit, tennis shoes, etc.

All students are expected to bring school supplies such as notebooks and pens. Students may bring their own computer; a computer lab will be available if necessary for the camp. Some camps may require specific clothing (e.g. closed toe shoes for a lab-based camp) - information will be emailed two weeks prior to the camp.

For safety reasons, do not bring jewelry, large amounts of cash, or other valuable items.

Residence Hall Information

Residential students will be housed in Hefley Hall (female) or Deaton Hall (male). These residence halls include furnished suites with two beds, two dressers, two desks, and two chairs. There are bathrooms shared with other residents on each floor. Some floors are equipped with a TV room, a kitchen with a sink, and vending machines. Students are allowed to bring their own mini-fridge.

Students will be given room assignments at check-in. For a more enriching cultural experience, students may be assigned a roommate from a different state, region, or country.

The University of Mississippi has strict policies for minors attending summer programs; therefore, all residential students participating in Pre-College Programs are required to live in the same residence as the rest of the students enrolled in the same program. No independent living arrangements are allowed for residential students. All students housed in University residence halls must abide by UM housing rules.

Items and Activities Not Allowed in Residence Halls (this list is not all inclusive): ALCOHOL, ILLEGAL DRUGS, CANDLES, INCENSE, SMOKING / VAPING, WEAPONS, COOKING APPLIANCES (personal toaster ovens, George Foreman style grills), PETS, HALOGEN LAMPS, DOUBLE-STICK TAPE, DUCT TAPE, TAMPERING OF FIRE SAFETY EQUIPMENT, REMOVAL OF FURNITURE FROM ROOMS OR COMMON AREAS, HANGING OR THROWING THINGS OUT WINDOWS, DAMAGING WALLS, DAMAGING FURNITURE, DAMAGING VENDING MACHINES, FIGHTING, STEALING, VANDALISM, HARASSMENT, HALL SPORTS, AND LOUD NOISES

All items and activities listed above are not allowed under any circumstances and are grounds for dismissal from the program, forfeiting all registration fees.

Students will be responsible for any damage to their residence hall room during their stay at the University. If students have any accidental damage, please notify program counselors immediately.

Residence Hall Information Acknowledgement and Agreement(Required)

I acknowledge and agree to the guidelines as outlined in Residence Hall Information.

Meal Plan

Residential: The meal plan allows students to have three (3) meals per day from Monday to Thursday and two (2) meals on Friday at the Rebel Market. The student’s meal plan is loaded on a card that they will receive at registration.

Commuter: The meal plan allows students to have lunch at the Rebel Market each day from Monday to Friday.

Meal Plan Information Acknowledgement and Agreement(Required)

I acknowledge and agree to the guidelines as outlined in Meal Plan Information.

Additional Guidelines

Leaving Campus during the Program: Due to the amount of activities hosted during the week, we strongly discourage requests to leave campus on weekdays. All requests must be submitted in writing to the Director of Pre-College Programs for review.

Visitors: Due to the strenuous schedule of activities during the program, off-campus visitors are not allowed during the week. For all students’ safety, no visitors are allowed in the students’ rooms, including parents, family members, and friends, unless they are assisting with move-in or move-out. Visitors are allowed to meet with students outside and social distancing is required.

Automobiles: If a student (residential and commuter) brings their automobile they must purchase a visitor’s parking permit from Parking and Transportation Services. The use of personal vehicles while in attendance to the program will be limited to traveling home on weekends and only with the permission of a parent and the Director’s approval. Students cannot drive their car at any other time. Vehicle keys should be turned in to a counselor as soon as unpacking is completed.

Transportation to and from Campus: The University can be accessed by plane, taxi, or private automobile. The nearest major airport is in Memphis, Tennessee. Students must arrange their flight to and from Memphis International Airport. Students planning to arrive by plane may contact our office to request a shuttle for an additional fee.

Additional Guidelines Acknowledgement and Agreement(Required)

I acknowledge and agree to the guidelines as outlined in Additional Guidelines.

Emergency

In the event of an emergency between the hours of 8:00 am and 5:00 pm (CST), please call our office at 662-915-7621. If the emergency happens after hours or during the weekend, please call the emergency number that will be provided during orientation. If an emergency occurs on campus, you must contact a counselor, staff, or the director immediately. Contact lists for the staff and other emergency numbers will be given at registration and orientation.

Rules Overview

All Pre-College Programs participants are expected to conduct themselves responsibly, honestly, and with due consideration for others. This expectation for mature and responsible conduct also encompasses accountability for one’s own well-being, including responsible decision-making regarding physical and mental health. All participants of Pre-College Programs must familiarize themselves with the general guidelines and the general rules. Because students are expected to show good judgement at all times, not every kind of misconduct or behavioral expectation is defined here. The following information is to advise students and parents of arrangements, rules, and general expectations.

Drugs and Other Substances Rules

The Office of Pre-College Programs has a zero tolerance policy for consumption, possession, distribution, solicitation, assistance in the acquisition, transmission, trafficking, manufacturing, or attempt to manufacture alcohol, tobacco, e-cigarettes/vaping, illegal drugs, or drug paraphernalia at any time while enrolled in any Pre-College Program, whether on campus, off campus, or at a private gathering.

**Participation in an incident or attending a gathering involving alcohol, illegal drugs, and/or the misuse of prescription drugs, or other means employed to induce results or effects similar to intoxication or impairment is cause for immediate dismissal from the program, even if the only evidence is social media.

Drugs and Other Substances Rules Acknowledgement and Agreement(Required)

I acknowledge and agree to the rules as outlined in Drugs and Other Substances Rules.

Violence and Assault Rules

Cases of assault and sexual misconduct are not tolerated in any Pre-College Program. If a student is a victim or a witness of a violent act or assault, the student must report it to a program counselor or the program director immediately. Pre-College Program staff will report it to University Police (662-915-7234), the Title IX Coordinator (662-915-7045), and Mississippi Department of Human Services (800-222-8000), and will provide a written notification as soon as possible thereafter. If the Program Director may be involved in the suspected assault or abuse, the student, parent, or program counselor should report the suspected assault or abuse to the University’s Title IX Coordinator (662-915-7045).

Bullying and Harrasment

Harassment of any kind, but particularly on the basis of identity or ability, is unacceptable and is in violation of the University of Mississippi M Book.

From the M Book: Students, visitors, and other individuals affiliated with the University have the right to an environment free of conduct that unreasonably interferes, hinders, or otherwise denies equal access to University resources or opportunities. Therefore, students, visitors, and other individuals affiliated with the University should refrain from harassing others and creating an environment that denies these rights (a “hostile environment”). Whether conduct creates a hostile environment that denies equal access to University resources or opportunities is based on the totality of the circumstances, and includes the following considerations:

The degree to which the conduct affects or affected one or more individuals’ ability to access an educational program or activity;
The type, frequency, and duration of the conduct;
The parties’ ages and roles within the education program or activity;
The previous interactions between the parties; and
The location of the conduct and the context in which it occurred.

For speech to violate this policy, the speech must be more than merely offensive; it must be so objectively offensive, pervasive, and severe that it effectively denies the victim equal access to the University’s resources and opportunities. This would include speech based upon race, color, gender, sex, sexual orientation, gender identity or expression, religion, national origin, age, disability, veteran status, or genetic information that is so objectively offensive to effectively deny the victim equal access to the University’s programs or activities.

This policy also prohibits the use of fighting words. Fighting words are abusive or insulting words or phrases: (1) directed toward an individual or group, (2) which by their very utterance inflict injury or are likely to provoke a violent reaction or cause the average person to retaliate, and (3) play no role in the expression of ideas and have little to no social value.

Online harassment is also judged according to the above framework. If such actions are reported to Pre-College Program staff, an investigation will be made. Any participant found to have engaged in creating a hostile environment that denies equal access to University resources or opportunities may be subject to disciplinary action that includes dismissal from the program without a refund.

Violence and Assault Rules Acknowledgement and Agreement(Required)

I acknowledge and agree to the rules as outlined in Violence and Assault Rules.

Visits to Other Buildings and Visitors in Building

It is strictly forbidden for a Pre-College Programs student to visit any other residence halls, fraternity or sorority houses, and campus apartments. These facilities are off-limits at all times. This includes the public lobbies of those facilities. Visiting other residence halls is cause for dismissal from the program.
No visitors are allowed in the students’ rooms, including parents or family members unless they are assisting with move-in or move-out during the scheduled move-in/move-out times.
Students cannot visit other students’ rooms after 10:00 pm. If it is an emergency, the student must contact a program counselor immediately. Failure to comply will result in disciplinary procedures.

Visits to Other Buildings and Visitors in Building Acknowledgement and Agreement(Required)

I acknowledge and agree to the rules as outlined in Visits to Other Buildings and Visitors in Building.

Leaving Campus Rules

Students are not allowed to leave campus without a program counselor, instructor, and/or staff members at any time unless the student is checked out by a parent/guardian. There is no exception to this rule; failure to comply will result in dismissal from the program.

Leaving Campus Rules Acknowledgement and Agreement(Required)

I acknowledge and agree to the rules as outlined in Leaving Campus Rules.

University Rules

All Pre-College Programs participants must abide by all University of Mississippi rules and regulations. This includes the University of Mississippi Minors on Campus policies, Residence Hall Code of Conduct, Academic Codes, UM Creed, and Pre-College Programs Rules. Failure to comply with any of these rules can lead to disciplinary procedures.
Students are expected to show respect for one another, for program staff, and for all people on campus.
Students are expected to participate constructively in program activities.

University Rules Acknowledgement and Agreement(Required)

I acknowledge and agree to the rules as outlined in University Rules.

Residential Program Rules

Pre-College Programs students living in any of the University residence halls must comply with Residence Halls Rules.
Students must attend announcements from Monday to Thursday at 4:30 pm at the designated location.
If a student is not in class, in a community activity, or with accompanied by a counselor, they must be inside their residence hall at all times.
Students must be inside their room by 10:00 pm every night.
Students must attend planned activities when they are scheduled.

Commuter Program Rules

Students must attend all sessions scheduled by instructor.
Commuter students are not allowed in residence halls unless parents have contacted the program director and made arrangements for the student to attend community activities.
Commuter students are not allowed to stay the night in the residence hall under any circumstances.

Residential/Commuter Program Rules Acknowledgement and Agreement(Required)

I acknowledge and agree to the rules as outlined in Residential/Commuter Program Rules.

Consequences for Rule Violations

Major versus Minor Rule Violations

Minor violations are when a student intends no harm or disrespect for the rules. For example, being too boisterous in the residence hall is usually a minor violation, as is being five minutes past curfew.
Major violations are when the student shows malice or disrespect for the rules or for other people. For example, intentionally harming another student is a major violation, as is breaking one of the program rules regarding safety or harassment (listed above). In the above minor violation examples, being boisterous in the residence hall rises to major level if someone is caused harm or if a student intentionally disregards warnings. A curfew violation would rise to major level if a student persisted in being late by more than 10 minutes, or if a student was being disrespectful by purposefully going past curfew.
Penalties for minor rule violations include loss of privileges.
Major rule violation will in most cases lead to dismissal from the program.

Major Rule Violation Review

If a student is suspected to have broken a major rule, staff will investigate. Pre-College Program staff will follow the steps below during the investigation:
If necessary, cell phones from all students involved will be collected (not searched).
Students will be separated and facts will be gathered. Depending on the severity of the situation, University Police could become involved at this step.
Once the investigation is over and a decision about action has been made, parents for all parties involved will be contacted and given a full report. If appropriate, reports will be filed with University offices.
One of two actions will be taken according to the rules and general guidelines of The University of Mississippi and the Office of Pre-College Programs:
- No major violation is found – Disciplinary action will be imposed at the discretion of professional staff.
- A major rule violation has occurred - Send student home. (All program and registration fees are non-refundable)

Consequences for Rule Violations Acknowledgement and Agreement(Required)

I acknowledge and agree to the policy as outlined in Consequences for Rule Violations.

Parent/Guardian Signature(Required)

Please type your name to certify that you acknowledge and agree to the Program Rules and Guidelines as outlined.

Photography Authorization(Required)

Do you authorize UM to capture this participant's name, image, voice, or likeness in still photograph and audio or video recording? I understand that UM may use this content at its sole discretion for its educational purposes in all forms of media, including social media. I understand that I have no edit, inspection, or approval rights. I release, hold harmless, and covenant not to sue UM for any claims that may arise out of the use of my name, image, voice, or likeness including but not limited to, any claims for defamation, invasion of privacy, or copyright infringement.

I AUTHORIZE UM to capture my student's name, image, voice, or likeness in still photograph and audio or video recording.

I DO NOT AUTHORIZE UM to capture my student's name, image, voice, or likeness in still photograph and audio or video recording.

Transportation - Off-Campus Trips(Required)

Do you authorize the UM Office of Pre-College Programs to take your student on off-campus trips for activities related to the day camp?

I AUTHORIZE UM to take my student on off-campus trips

I DO NOT AUTHORIZE UM to take my student on off-campus trips

Transportation - Rides in UM Vehicles(Required)

Do you authorize the UM Office of Pre-College Programs to transport your student in a University of Mississippi vehicle?

I AUTHORIZE UM to transport my student in a University of Mississippi vehicle

I DO NOT AUTHORIZE UM to transport my student in a University of Mississippi vehicle

Parent/Guardian Signature(Required)

Please type your name to certify the above permissions authorized by you.

COVID Compliance and Liability Waiver Overview

The University of Mississippi requires all summer program participants to complete the below waivers in order to participate. All participants' parents/guardians must complete and certify the "COVID-19 Compliance, Liability Waiver, and Assumption of the Risk Addendum." Students participating in a residential summer program, meaning the student will stay on-campus overnight, will need to have the UM Department of Student Housing's "COVID-19 Summer Housing Acknowledgment" form completed and certified by both student AND parent/guardian.

COVID-19 Compliance, Liability Waiver, and Assumption of the Risk Addendum

To be completed by parent/legal guardian.

The novel coronavirus, COVID-19, is a highly infectious, life-threatening disease declared by the World Health Organization to be a global pandemic. COVID-19’s highly contagious nature means that contact with others, or contact with surfaces that have been exposed to the virus, can lead to infection. Additionally, individuals who may have been infected with COVID-19 may be asymptomatic for a period of time, or may never become symptomatic at all. Because of its highly contagious and sometimes “hidden” nature, it is currently very difficult to control the spread of COVID-19 or to determine whether, where, or how a specific individual may have been exposed to the disease.

I understand that in accordance with current Center for Disease Control guidance, it is highly recommended that all persons continue to wear face masks; adhere to social distancing, including, limiting social gatherings to small numbers; and, that getting vaccinated is encouraged when it is made available.

I agree that if my student is exhibiting symptoms or if, to my knowledge, my student has been in contact with anyone diagnosed with COVID-19 or is exhibiting symptoms of respiratory illness, loss of taste or smell, a fever of 100.4°F or higher, or signs of a fever within the last 14 days, my student will not participate in the Ole Miss Summer Program (“Summer Program”).

By signing up to attend the Summer Program, I acknowledge the contagious nature of COVID-19, the fact that it can be difficult to identify in another, and the inherent risks of exposure in a social setting to those who may be infected with COVID-19. I knowingly and voluntarily assume the risk that I and/or my student may be exposed to or infected with COVID-19 by participating in the Summer Program. I knowingly and voluntarily waive and release UM from all present and future claims of any type for any harm or loss, including economic loss, personal injury, death, or property damage suffered by me and/or my student and arising out of my student's participation in the Summer Program. I agree to indemnify, hold harmless, and covenant not to sue UM for any damages, personal injury, death, medical expenses, disability, lost wages, loss of capacity, property damage, court costs, attorney’s fees, or any other loss of any kind.

I acknowledge that I have asked for and/or been given any information that I may need to determine the risks associated with my student participating in the Summer Program, and to make an informed assumption of those risks. Aware of the foregoing, I am knowingly and voluntarily allowing my student to participate in the Summer Program.

Hidden

Has this student tested positive for COVID-19?

Yes

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If "YES," what date did the student test positive?

Hidden

Has this student fully recovered from COVID-19?

No - this student has not had COVID-19

No - this student has not fully recovered from COVID-19

Yes - this student has fully recovered from COVID-19

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Do you understand that all participants will be asked to self-monitor for symptoms and screened for symptoms to include temperature checks as deemed appropriate by medical staff?

Yes

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COVID-19 Symptom Reporting

I understand that while my student is participating in the Summer Program I and my student will immediately report the following symptoms if they occur: cough, shortness of breath, fever, chills, muscle pain, fatigue, headache, sore throat, congestion or runny nose, nausea/vomiting, diarrhea, and new loss of taste or smell.

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Parent/Guardian Certification

I HAVE READ AND UNDERSTAND THIS AGREEMENT AND I AM AWARE THAT BY SIGNING THIS AGREEMENT I MAY BE WAIVING CERTAIN LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE. THIS AGREEMENT SHALL BE BINDING UPON ME AND MY HEIRS, LEGAL REPRESENTATIVES, AND ASSIGNS, AND SHALL INURE TO THE BENEFIT OF THE UNIVERSITY AND THEIR SUCCESSORS AND ASSIGNS.

My signature below indicates that I have read and understand the above statements and intend to be bound legally by its terms.

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Parent/Guardian Signature

Please type your name to certify this section.

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COVID-19 Summer Housing Acknowledgment

To be completed by parent/legal guardian.

In an effort to minimize the risk of infection and help slow the spread of COVID-19, all persons residing in a residence hall at the University of Mississippi (the “University”) must abide by the COVID-19 terms specified below. The limitations specified in this Acknowledgment are based on what is currently known about the transmission and severity of COVID-19 at the time, as communicated by the U.S. Centers for Disease Control and Prevention (CDC). The University will update its housing policies and may further amend this Acknowledgment, as needed, as additional information and public health recommendations regarding COVID-19 become available.
I understand this Acknowledgment outlines expectations specific to COVID-19 and must be completed fully to stay in conference housing at the University for summer 2023.
I understand that I must comply with all University policies or protocols related to COVID-19.
I acknowledge and agree that, if I exhibit any signs or symptoms of COVID-19, as enumerated by the CDC at https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html, or if I have been in close contact (i.e., within six (6) feet of someone for more than fifteen (15) minutes who has tested positive for COVID-19) and am not fully vaccinated, it is my responsibility to notify the University’s Department of Student Housing (“Student Housing”) designee and immediately self-isolate or quarantine (as directed). Quarantine and self-isolation mean NO human contact with ANYONE, including family, friends, and especially going out into the public. I understand that if symptoms are mild, this does not mean that the virus cannot be spread to someone else and put others at severe risk.
I understand that if I need to self-quarantine or isolate because of COVID-19, I will adhere to our group’s COVID readiness plan and contact the Student Housing designee.
I acknowledge and agree that, in the event of a medical emergency, 911 will be called, and the operator will be notified if I may have COVID-19. A face covering should be put on before medical help arrives.
I acknowledge and agree that, if I receive a positive test result for COVID-19 while in conference housing, I will report it to the Student Housing designee immediately.
I understand that, if I have been exposed to COVID-19 (and are not fully vaccinated), diagnosed COVID-19 positive, or directed to self-quarantine or isolate because of COVID-19, I may be required to vacate Student Housing facilities so as not to jeopardize the health or the health and safety of others. I acknowledge that Student Housing may utilize a short-term holding area for any affected person.
I understand that overnight stays in a residence hall could increase my risk of contracting any contagious disease because of the dense populations in the residence halls.
I understand that the best way to reduce risk of exposure and minimize the spread of COVID-19 to is to follow the public health recommendations issued from the CDC, and therefore I agree to:

Wash hands often with soap and water for a least 20 seconds.
Use hand sanitizer, with 60-95% alcohol if soap/water is not available.
Avoid touching eyes, nose, or mouth with unwashed hands.
Avoid contact with people who are sick.
Stay home if sick and avoid close contact with others.
Cover mouth and nose with an elbow or a tissue when coughing sneezing, and immediately dispose of the used tissue.
Wear face coverings as may be required by the University, the City of Oxford, and/or the State of Mississippi.
Clean and disinfect frequently touched objects and surfaces in assigned room.

I understand that I am participating in a conference that involves an overnight stay in a communal living environment during a global pandemic. The University cannot guarantee that participants will not be exposed to or contract COVID-19 or another communicable disease. It is understood that there are known and unknown risks that could affect the health, safety, and well-being, including but not limited to illness, injury, temporary or permanent impairment, and death of participants. I acknowledge that I knowingly elect to participate in an overnight stay within a residence hall with a full understanding and acceptance of these risks and without any undue pressure or coercion.
I understand that this Acknowledgment is intended to protect the health and safety of myself and all conference participants. Any non-compliance with the terms of this Acknowledgment may result in my removal from conference housing. I acknowledge and agree that if I am removed for failing to comply with this Acknowledgment, no housing fees will be adjusted or refunded.
I understand that the Department of Student Housing will not offer quarantine and isolation housing to conference participants who are under the age of 18-years old.
I acknowledge and agree that if I must vacate Student Housing for COVID related concerns, no housing fees will be adjusted or refunded.

COVID-19 Housing - Student Certification

I have read, understand, and agree to the Department of Student Housing's COVID-19 Housing Acknowledgment as described.

COVID-19 Housing - Student Signature

Please type your name (student) to certify this section.

COVID-19 Housing - Parent/Guardian Certification

I have read, understand, and agree to the Department of Student Housing's COVID-19 Housing Acknowledgment as described.

COVID-19 Housing - Parent/Guardian Signature

Please type your name to certify this section.

Final Notes Before Submission

The Summer Programs Application is Step Two of three major steps required to be completed by the student or parent/legal guardian.

The immediate next step in the process upon submission of this form is to:

Upload Medical Forms and supporting documentation using the secure upload site (instructions to be sent via email)

Following the submission of this application, you will receive automatic emails that detail how to complete and upload the Medical Form and supporting documentation; additional information regarding any post-registration processes; and a receipt of agreements and certifications marked in this form for your records.