Parental Consent Form

 Parental Consent Form (for those under the age of 18) Parents and legal guardians of minor children must complete this form and return it to the University. The information requested is designed to assist the University in providing for the safety of minors during the Summer School activities. Child’s Name: ______________________________________________________________________ Father’s Name: _____________________________________________________________________ Mother’s Name: ____________________________________________________________________ Child’s Address: _____________________________________________________________________ City: State: zip/postcode: _____________________________________________________________ Home Phone: _______________________________________________________________________ Work Phone: _______________________________________________________________________ Mobile Phone: ______________________________________________________________________ E‐mail: ____________________________________________________________________________ Medical Questionnaire: 1. Is your child presently being treated for an injury or sickness or taking any form of medication for any reason?  Yes. If yes, please explain and list any medications. _________________  No 2. Is your child allergic to any type of medication?  Yes. If yes, please explain and list any medications. _________________  No 3. Does your child medically require a special diet?  Yes. If yes, please explain and list any medications. _________________  No 4. Does your child have (or has ever had) any of the following? (Check all that apply and explain.)  Seizures  Asthma  Heart Murmur  Diabetes  Hay Fever  Kidney Disease  Other: ___________________________________________________________ 5. Does your child have any allergies?  Yes. If yes, please explain and list any medications. _________________  No 6. Has your child ever sleep walked?  Yes  No 7. Can your child swim?  Yes  No 8. Does your child have any physical condition or illness which would prevent him/her from participating in normal, rigorous activity?  Yes. If yes, please explain and list any medications. _________________  No Medical Treatment Authorization We understand that we will be notified in the case of a medical emergency involving our child. However, in the event that we, or either of us, cannot be reached, we authorize the calling of a doctor and the providing of necessary medical services in the event out child is injured or becomes ill. We authorize any adult leader participating on this trip or any Cyprus International University Staff to make emergency medical care decisions on behalf of our child, if required by law or a health care provider. We understand that Cyprus International University, or any of their agents, employees, or volunteers, will not be responsible for medical expenses incurred on the basis of this authorization. We agree to notify the University in the event of any health changes which would restrict our child’s participation in any activities. We also understand that the adult Staff members of the University reserve the right to restrict our child from any activity that they do not feel is within the physical capabilities of my child. Home Phone: _____________________ E‐mail: __________________________ Father’s Work: ____________________ Mother’s Work: ___________________ Father’s Cell: _____________________ Mother’s Cell: _____________________ Emergency Contact Name: ____________________________________________________________ Emergency Contact Number(s): ________________________________________________________ Family Doctor: ______________________________________________________________________ Doctor’s Phone Number__________________________________________________________ Terms and Conditions International Summer Academy 2015 1. This statement must be signed by the parent or legal guardian and returned to CIU Admission Office as one of the required documents for Unconditional Acceptance letter. 2. Fees listed in the letter of acceptance cover program fee depending on selected number of weeks and accommodation deposit fee. i.
Program Fee includes tuition, accommodation, meal plan, excursions, and on‐
campus entertainment activities. ii.
Accommodation deposit fee of € 250 is refundable. According to the terms of the residence contract, students are responsible for the condition of their room and any shared spaces. Deposit will be refunded in cash in full on the departure date in case if there will be no room damages. iii.
Some of the activities will be extra charged (e.g. bowling, cinema, yacht tour e.t.c.). iv.
Entertainment activities are not obligated for participation. v.
Flights are not included in the Program Fee 3. Refunds of deposits and/or advanced payments of tuition fees or package program payments will be made only in the event of a refusal of visa application, unless the documents submitted to the Embassy were not verifiable. Students will need to provide evidence of visa refusal. Refunds will not be made other reasons. 4. In case if student cancels participation after the payment, the program fee is not going to be refunded. 5. CIU Arena sports hall membership is included into the program fee. 6. Students are required to provide Unconditional Acceptance Letter and signed “Terms and Conditions” document for completion of the registration. 7. Money transfers between the accounts of different students are not allowed. 8. Money transfers made to the accounts of the university, including those from the parents of the students, will only be transferred to the account of the student by the signed permit of the sender. 9. Residence Halls will accept students each Sunday starting from the initial entry date stated on the Conditional Acceptance Letter. Limited on campus accommodation may be available subject to a daily fee based on dormitory type. The university does not guarantee the availability of accommodation before the dates stated on the Conditional Acceptance Letter. Consent I (We), the undersigned, being the parent(s) or legal guardian(s) of the child named above, do hereby consent to the participation of my (our) child in Cyprus International Summer School trip during _______ (year), including swimming, horse riding, hiking, sports events, and any other activities customarily associated with a CIU Summer School. Further, I (we) certify my (our) child is physically able to and adequately trained to participate in such events. (If you do not wish your child to participate in a particular type of activity please let us know here: I (We) do not authorize our child to participate in any of the following activities: _____________________________. Model Release and Marketing Consent. I, ________________________________, do hereby give Cyprus International University, and any/all of their licensees and legal representatives the irrevocable right to use my child’s name (or any fictional name), picture, portrait, or photograph in all forms and media and in all manners, including but not limited to, composite or distorted representations, for advertising, trade, or any other lawful purposes, and I waive any right to inspect or approve the finished product, including written copy, that may be created in connection therewith. I verify that I am the parent/guardian of the minor named above and have the legal authority to execute the above release. I have read this release and fully understand its contents. I approve the foregoing and waive any rights in the premises. Original Parental Consent Form should be submitted upon arrival in order to be registered for the Programme. I have read, understood and accepted the Cyprus International University International Summer Academy Terms and Conditions. Name, Surname: Signature: Date: