2016 REGISTRATION FORM • GREAT VALLEY WRITING CAMPS

2016 REGISTRATION FORM • GREAT VALLEY WRITING CAMPS • Page 1 of 7
GVWP is a small nonprofit organization. It is difficult for our tiny office staff to process paper registration forms and
phone orders, so we offer substantial discounts for online registration. Go to www.greatvalleywriting.org for details.
SELECT A SITE!
❐ RIPON: June 6-17 (serves TK-12th grade)
Parent / Legal Guardian – First Name:
E-Mail Address:
❐ ESCALON: June 20-July 1 (serves K-6th grade)
Last Name:
for confirmation message &
any important notifications
Home Address:
City:
Zip Code:
Emergency daytime phone (list the phone number we should call first):
Other parent/guardian phone (list the number we should call next):
Alternate Name:
Emergency
Contacts: Name:
Name of Student – First Name:
Current Grade Level:
This Student’s School:
Relationship:
Phone:
Relationship:
Phone:
Last Name:
In a mixed-age group, does your child perform better with students who
are one year OLDER, or with students who are one year YOUNGER?
❐ OLDER
❐ YOUNGER
School District:
Special Learning Needs:
Medical Concerns:
Additional Student – First Name:
Current Grade Level:
This Student’s School:
Last Name:
In a mixed-age group, does your child perform better with students who
are one year OLDER, or with students who are one year YOUNGER?
❐ OLDER
❐ YOUNGER
School District:
Special Learning Needs:
Medical Concerns:
Additional Student – First Name:
Current Grade Level:
This Student’s School:
Last Name:
In a mixed-age group, does your child perform better with students who
are one year OLDER, or with students who are one year YOUNGER?
❐ OLDER
❐ YOUNGER
School District:
Special Learning Needs:
Medical Concerns:
I hereby certify that I am the parent/guardian of the above-named student(s), and I am in agreement with, and give my
consent for, his/her/their attendance at the Great Valley Writing Camp. To the best of my knowledge, I verify that the
information on this application form is correct.
Signature of Parent/Legal Guardian: ________________________________________ Date: ______________________
2016 REGISTRATION FORM • GREAT VALLEY WRITING CAMPS • Page 2 of 7
COST TO REGISTER BY MAIL: (...but online registration through www.greatvalleywriting.org is less expensive.)
Postmarked March: $165 • Postmarked April: $175 • Postmarked May: $185 • Postmarked June: $190
PAYMENT CALCULATOR AND CHECKLIST:
ALL PAGES of this packet must be signed!
Send the completed packet (plus check)
to the following address:
Great Valley Writing Project at CSU Stanislaus
One University Circle, Suite DBH318
Turlock, CA 95382
Enter the base price for one student enrollment:
• Postmarked in March = $165
• Postmarked in April = $175
• Postmarked in May = $185
• Postmarked in June = $190
Checks are payable to GVWP at CSU Stanislaus.
Enter the number of students you wish to enroll:
Forms must be mailed at least one week prior
to the opening date of the workshop.
Acceptance is dependent on available space.
Multiply to calculate the AMOUNT DUE:
AUTHORIZATION FOR MEDICAL TREATMENT
Agreement of parent or guardian is required for enrollment.
In a medical situation where teachers are unable to reach a parent or legal guardian, or when the parent or
guardian is unable to arrive on the scene in a timely manner, I grant my authorization and consent for the
teachers of the Great Valley Writing Camp to administer general first aid treatment for any minor injuries or
illnesses experienced by the student(s) during the workshop.
If the injury or illness is life-threatening or in need of emergency treatment, I authorize the teachers at the
Great Valley Writing Camp to summon any and all professional emergency personnel to attend, transport, and
treat the child/children.
Furthermore, when no parent/guardian is present to act on the child’s behalf, I authorize the Great Valley
Writing Camp to act as my representative in giving consent for the aforementioned child/children to receive
emergency medical services, including any x-ray, anesthetic, blood transfusion, medication, or other medical
diagnosis, treatment, or hospital care that is deemed advisable by (and rendered under the general supervision
of) any licensed physician, surgeon, dentist, hospital, or other medical professional or institution duly licensed
to practice in California.
It is understood that this authorization is given in advance of any such medical treatment, but is given to
provide authority and power on the part of the Designated Adult in the exercise of his or her best judgment upon
the advice of any such medical or emergency personnel.
AUTHORIZATION OF PARENT OR GUARDIAN:
I hereby verify that I have read and understand the Authorization for Medical Treatment, and I hereby authorize the Great
Valley Writing Camp to act as my representative in giving consent for the aforementioned minor(s) to receive first aid
and/or emergency medical services.
Signature of Parent/Legal Guardian: ________________________________________ Date: ______________________
2016 REGISTRATION FORM • GREAT VALLEY WRITING CAMPS • Page 3 of 7
PUBLICATION AGREEMENT FOR GREAT VALLEY WRITING CAMPS
Agreement of parent or guardian is required for enrollment.
You must read, agree with, and accept all of the terms and conditions contained in this Agreement in order to
enroll your child/children in the Great Valley Writing Camps.
By signing below, you indicate approval for each enrolled student’s name, picture, art, written work, voice,
verbal statements, or portraits (video or still) to appear in informational and/or educational publications, videos,
or websites. For example, pictures, articles, and video about the “Writing & Technology Workshop” might
appear in local newspapers, in student-published anthologies, in program-affiliated websites, or in informational
television broadcasts. These pictures and articles may or may not personally identify the student. The program
partners may continue to use the pictures and/or videos in subsequent years. (Program partners may include
CSU Stanislaus, County Offices of Education, Give Every Child a Chance, the California Writing Project, and
the National Writing Project, and public or private schools and districts that allow use of their facilities.)
GVWP has no control of pictures/statements taken by participating students or outside parties that might be
shared without our permission.
Publication Agreement: The Student and Parent/Guardian release to Great Valley Writing Project (GVWP) the
student's name, picture, art, written work, voice, verbal statements, portraits (video or still), and consent to their
use by program partners. For student protection, GVWP will follow these guidelines:
! Each student's name, picture, art, written work, voice, verbal statements, portraits (video or still) shall be
used only for public relations, program information/promotion, teacher education, and classroom
instruction.
! In website postings, student authors will not be identified by personal details other than first and/or last
name. (We will NOT include student e-mail addresses, postal addresses, telephone, or fax numbers.)
! Great Valley Writing Project will accede to any written request by a parent or legal guardian for the
removal of specific photographs featuring their child, or references to their child’s name.
The Student and Parent/Guardian understand and agree that:
! No remuneration or compensation (i.e.: money) shall be paid for any published material;
! Consent and release have been given without coercion or duress;
! This agreement is binding upon heirs and/or future legal representatives;
! Photos, videos, writing samples, or student statements may be used in subsequent years.
Please note: We publish student work quickly, because seeing their projects in print inspires students to review,
revise, and refine their writing. Thus, no other signed waiver will be sought or required prior to publishing
student work.
AUTHORIZATION OF PARENT OR GUARDIAN:
I hereby verify that I have read the policies and guidelines listed above, and I grant permission for publication
of workshop products and images in accordance with those policies.
Signature of Parent/Legal Guardian: ________________________________________ Date: ______________________
2016 REGISTRATION FORM • GREAT VALLEY WRITING CAMPS • Page 4 of 7
INTERNET USE AGREEMENT FOR GREAT VALLEY WRITING CAMPS
Agreement of parent or guardian is required for enrollment.
You must read, agree with, and accept all of the terms and conditions contained in this Agreement in order to enroll
your child/children in the Great Valley Writing Camps.
TECHNOLOGY IS AN INTEGRAL PART OF THIS PROGRAM. In order to participate in this program, students are
required to use computers and access the internet as part of daily class instruction. Please read the following rules and
policies, and make sure that you and your children agree before you decide to enroll.
RULES FOR STUDENT USE OF COMPUTERS AND INTERNET:
1. Students will show respect for school equipment and computer networks.
2. Students will not use a computer account, ID, or password other than their own.
3. Students will show respect for the digital property of others; they will not attempt to gain unauthorized access (i.e.
hacking) into any network, system, program, or account, and they must immediately report any inappropriate attempts
at access or violations of privacy to the teacher.
4. Students will not intentionally access, produce, post, send, display, and/or retrieve vulgar, obscene, offensive, or
otherwise inappropriate materials. They will immediately notify teachers of any inappropriate or disturbing material
they encounter on the web or in electronic communications.
5. Students will not give personal information (phone #, email, street address, etc.) to anyone on the internet.
6. Students will gain clearance from the teacher before downloading files from the internet.
7. CDs, flashdrives, or other digital storage devices are discouraged; instead, students are encouraged to access their
projects via the internet. Students who bring digital storage devices must submit them to be scanned for viruses and
approved by the teacher.
Violation of any of these rules may result in forfeiture of permission to use the internet, expulsion from the program,
and/or criminal charges.
PRIVACY ISSUES: Students should not expect that files stored on school system servers and workstations will be private.
The school system may monitor equipment structures and systems, and all data stored or transmitted on school computers,
in order to ensure the security and performance of its equipment, systems, and networks and to enforce applicable laws
and policies.
POSSIBILITY OF INAPPROPRIATE CONTENT: Although school computers have some built-in filters intended to block
inappropriate content, and computer labs are monitored by classroom teachers, our workshop leaders cannot guarantee
that staff members will intercept all inappropriate material and/or every inappropriate use of the internet.
AUTHORIZATION OF PARENT OR LEGAL GUARDIAN:
By signing below, I verify that I have read and understand this agreement, and I grant permission for my child/children
to use the internet. I further agree that I will indemnify the host school district for any fees, expenses, or damages incurred
as a result of my children’s use or misuse of the computer network or equipment.
In addition, I verify that I have discussed appropriate and inappropriate use of the computer network with my children. I
indicate my understanding that the internet contains text and graphic files which are inappropriate for minors, and that the
network administrators cannot monitor all use. I release Great Valley Writing Project, other program sponsors, and their
school and community partners from any responsibility should any of my children be exposed, through his/her own
actions, or through the actions of another patron, to internet content of which I would not approve.
Signature of Parent/Legal Guardian: ________________________________________ Date: ______________________
2016 REGISTRATION FORM • GREAT VALLEY WRITING CAMPS • Page 5 of 7
AUTHORIZATION TO USE GOOGLE APPS FOR EDUCATION
Teachers and students at Great Valley Writing Camp often utilize online resources provided by Google Apps for
Education. This form describes the Google tools and outlines student responsibilities for using these services. Additional
information (including answers to Frequently Asked Questions about Google Apps) can be found in our website –
https://goo.gl/U5tJU6
As part of Great Valley Writing Camp’s online presence in Google Apps for Education, the following services (which are
hosted by Google) might be available to each student:
Mail– an individual email account for school use, managed by GVWP leaders and educational technology partners
Calendar – an individual calendar providing the ability to organize schedules, daily activities, and assignments
Docs– a toolset for word processing, spreadsheet, drawing, and presentation (similar to Microsoft Office)
Drive – individual and community spaces for storing and sharing project files online
Sites– an individual and collaborative website creation tool
Using these tools, students may collaboratively create, edit, and share files and webpages for projects; they may also
communicate via email with other students and teachers. These services are entirely online and available 24/7 from any
internet-connected computer. Examples of typical student use include creating group presentations, building an online
portfolio of learning experiences, and showcasing class projects.
Technology use at Great Valley Writing Camps is governed by COPPA (Children's Online Privacy Protection Act)–This federal
law applies to commercial companies and limits their ability to collect personal information from children under 13 years.
By default, advertising is turned off for Great Valley Writing Camp’s presence in Google Apps for Education. No
personal student information is collected for commercial purposes. This permission form allows GVWP and school
district partners to act as agents for parents in the collection of information within the workshop context. GVWP’s use of
student information is solely for education purposes. For more info, go to –http://www.ftc.gov/privacy/coppafaqs.shtm
Guidelines for the responsible use of Google Apps for Education by students:
1.Student Email Address. Participating students will be assigned an email account; the email address will be shared with
parents. This account will be used during the workshop and may be deleted when the workshop ends.
2.Prohibited Conduct. Please refer to the “Internet Use Agreement” for Great Valley Writing Camps. You may access a
printer-friendly copy of this form at this weblink – https://goo.gl/IloJDc
3. Access Restriction. Access to and use of student email is considered a privilege accorded at the discretion of the
program leaders. GVWP leaders and educational technology partners maintain the right to immediately withdraw the
access and use of these services (including email) when there is reason to believe that violations of law or violations of
internet use policies have occurred. In such cases, the alleged violation will be referred to a program administrator for
further investigation and adjudication.
4. Security. The Great Valley Writing Camp cannot and does not guarantee the security of electronic files located on
Google systems. Although Google does have a powerful content filter in place for email, we cannot assure that student
users will not be exposed to unsolicited information.
5. Privacy. Because the writing in this program is shared, discussed, and published, mentor-teachers at the Great Valley
Writing Camp will be encouraged to access and respond to student projects stored in Google Apps. In addition, GVWP’s
educational technology partners may access student files in Google systems, including current and archival files of user
accounts, when there is reasonable suspicion that unacceptable use has occurred. Student email users, however, are strictly
prohibited from accessing files and information (other than their own) without a specific invitation to do so.
continued on next page
2016 REGISTRATION FORM • GREAT VALLEY WRITING CAMPS • Page 6 of 7
AUTHORIZATION TO USE GOOGLE APPS FOR EDUCATION:
Student Email, Calendar, Documents, Drive, & Sites
By signing below, I confirm that I have read and understand the following:
By virtue of this online environment, I understand that my student’s education records stored in
Google Apps for Education may be accessible to someone other than my student and the Great Valley
Writing Camps. My signature below confirms my consent to allow my student’s educational activities
to be stored by Google.
I understand that by participating in Google Apps for Education, information about my child will be
collected and stored electronically. I have read the privacy policies associated with use of Google Apps
for Education (http://www.google.com/a/help/intl/en/edu/privacy.html). I understand that I may ask for
my child's account to be removed at any time, but that such action will prevent the student from
engaging in collaborative writing, editing, and revision activities during the workshop.
I hereby give permission to Great Valley Writing Camp, GVWP, the hosting school district, and/or an
affiliated county office of education to assign a Google Apps for Education account for each of the
children I have enrolled. I understand that if classroom teachers decide to use Google Apps in their
lessons, my child will receive an email account, plus access to Google Docs, Google Drive, Google
Calendar, and/or Google Sites. I understand that the accounts are not provided for permanent use, and
that they may be terminated shortly after the end of the workshop.
Signature of Parent/Legal Guardian: ________________________________________ Date: ______________________
2016 REGISTRATION FORM • GREAT VALLEY WRITING CAMPS • Page 7 of 7
INDEMNIFICATION & HOLD HARMLESS AGREEMENT
GVWP GREAT VALLEY WRITING CAMPS
Agreement of parent or guardian is required for enrollment.
Waiver of Liability, Assumption of Risk, and Indemnity Agreement
By signing below, you agree to be bound by the terms of the following waiver: In consideration of being
permitted to participate in any way in the Great Valley Writing Camp, herein after called the “Activity” or
“Workshop”, I, for myself, for the minor(s) in question, and for my heirs, personal representatives, executors, or
assigns, do hereby release, waive, discharge, and covenant not to sue the Program Sponsors and/or their
school and community partners (including Great Valley Writing Project, California Writing Project, National
Writing Project, public or private schools, school districts, and/or county offices of education who provide
facilities, services, and/or equipment, GECAC, California State University Stanislaus, The Regents of the
University of California, and all affiliated officers, employees, and agents) from liability from any and all
claims including the negligence of the Program Sponsors, their officers, employees and agents, resulting in
personal injury, accidents or illnesses (including death), and property loss arising from, but not limited to,
participation in the Great Valley Writing Camp.
Assumption of Risks: Participation in Great Valley Writing Camp carries with it certain inherent risks that
cannot be eliminated regardless of the care taken to avoid injuries. In addition to traditional classroom seatwork,
students will engage in a variety of physical activities, including, but not limited to, organized games within
classrooms, outdoor play activities during recess periods, and rehearsals for group performances. The specific
risks vary from one activity to another, but the risks range from (1) minor injuries such as scratches, bruises, and
sprains; (2) major injuries such as eye injury or loss of sight, joint or back injuries, heart attacks, and
concussions; (3) catastrophic injuries including paralysis and death.
I have read the previous paragraphs and I know, understand and appreciate these and other risks that
are inherent in Great Valley Writing Camp activities. I hereby assert that my participation is voluntary
and that I knowingly assume all such risks.
Indemnification and Hold Harmless: I also agree to indemnify the Program Sponsors and/or their school
and community partners (including Great Valley Writing Project, the California Writing Project, the National
Writing Project, public or private schools, school districts, and/or county offices of education who provide
facilities, services, and/or equipment, GECAC, California State University Stanislaus, The Regents of the
University of California, and all affiliated officers, employees, and agents) and to hold the aforementioned
Program Sponsors and partners harmless from any and all claims, actions, suits, procedures, costs,
expenses, damages and liabilities, including attorney’s fees brought as a result of my involvement in Great
Valley Writing Camp and to reimburse them for any such expenses incurred.
Severability: The undersigned further expressly agrees that the foregoing waiver and assumption of risks
agreement is intended to be as broad and inclusive as is permitted by the law of the State of California and that
if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal
force and effect.
Acknowledgment of Understanding: I have read this waiver of liability, assumption of risk and indemnity
agreement, fully understand its terms, and understand that I am giving up substantial rights, including my
right to sue. I acknowledge that I am signing the agreement freely and voluntarily, and intend by my
signature to be a complete and unconditional release of all liability to the greatest extent allowed by law.
Signature of Parent/Legal Guardian
Date