2017
South Florida Leadership
Training Camp
AND
sponsored by
The Department of Student Activities and Athletics
The School Board of Broward County, FL
1
2
The
South Florida Leadership
Training Camp
and
Camp Eagle Advanced Training
Camp
At
Nova Southeastern University
July 17, 2017 through July 21, 2017
sponsored by
The Department of Student Activities and Athletics
The School Board of Broward County, FL
3
What is the South Florida Leadership Training Camp (SFLTC)?
4
SFLTC is a four-day leadership workshop for high school student government leaders.
Student leaders who attend this workshop will be given an opportunity to participate in a
variety of leadership development activities that are conducted in both small and large
groups.
What is Camp Eagle-Advanced Leadership Training (Camp Eagle)?
Camp Eagle is also four-day advanced edition leadership workshop for high school student
government leaders who have completed the “South Florida Leadership Training Camp
or a similar development leadership camp. Student leaders who attend this workshop will
be given an opportunity to participate in a variety of advanced leadership development
activities that are conducted in small groups.
Both camp sessions will be devoted to specific areas including:
A. Goals, Aims, and Objectives of Student Government
B. Self-Awareness and Group Dynamics
C. Parliamentary Procedure
D. Problem Solving and Decision Making
E. Planning, Organization, and Time Management
F. Goal Setting
G. Communication
H. Evaluation
In addition, student leaders will have the opportunity to share ideas and projects,
demonstrate their own unique abilities, and make friends and contacts with students from
throughout the state.
Who is sponsoring these workshops?
Both SFLTC and Camp Eagle are sponsored by the Department of Student Activities of the
School Board of Broward County, Florida.
Who is on the instructional staff?
The staff consists of professional educators and students who have leadership and leadership
workshop experience.
The adult staff consists of teachers who have been or who are currently student activities
advisors in Florida high schools. These adult staff members have served on the staff of
numerous leadership workshops and have many years experience in student leadership
development.
The Junior Counselors are students who have graduated from high school and who have
volunteered to be Junior Counselors.
They are selected on the basis of the
recommendations by their student council advisor and their workshop experience.
Where is the workshops held?
SFLTC and Camp Eagle workshops run simultaneously and will be held on the campus of
Nova Southeastern University in Davie, Florida. General sessions, small group sessions,
and student housing will all be held in The Commons Building located at the south end of
the campus. All student meals will be served in the Rosenthal Student Union.
5
When will the workshops be held?
Both workshops will start on Monday, July 17, 2017, and end on Friday, July 21, 2017.
Registration will start at 11:00a.m. on Monday and the first general session will convene at
2:00p.m. The workshop will end at 11:00a.m. on Friday, July 21, 2017.
What kind of accommodations will the delegates have?
SFLTC/Camp Eagle staff will make all room assignments. Students will be housed one to a
room, in a four-room suite and delegates from the same school will not be assigned as
roommates. Delegates from the same school should not plan to share personal items.
Delegates must provide their own towels, as well as a pillow and linens (including a light
blanket) for a “long” twin bed.
How do delegates get to the workshops?
Delegates must make their own arrangements to reach Nova Southeastern University or to
the various public transportation depots in Ft. Lauderdale, Florida. If students drive
themselves to the workshop, they will not be allowed to drive their vehicles from the time of
their arrival until the workshop is over.
A map to the Davie campus of Nova Southeastern University is enclosed. There are signs
on the NSU campus to direct delegates to the dormitory, where the registration will take
place.
Is there a dress code?
Yes. The camp will provide a different tee shirt for three days (Tuesday through Thursday)
and if possible bring a “school” shirt for Friday. We recommend shorts be worn whenever
possible keeping in mind the dress code specified by the School Board of Broward County
as it will be enforced. A copy of that dress code is enclosed.
Are there other rules of conduct that will be enforced?
Yes. Most of them will be discussed at the workshop’s first general session however; a few
should be mentioned here.
Any delegate who is found in possession of drugs or alcoholic beverages, or who leaves the
Nova Southeastern campus, or who is found in the room of a member of the opposite sex,
will be sent home at his/her parent’s expense. In addition, his/her principal will be
immediately notified.
What should a delegate bring?
1.
2.
3.
4.
5.
6.
7.
A pillow, towels and bed linen (light blanket included) for a long twin bed.
A pencil or pen (these are needed at each session).
Sunscreen
Alarm Clock
Sweatshirt or light jacket
A positive attitude and open mind.
Extra money for film, snacks, etc…
6
Can a delegate bring a musical instrument, camera, or radio?
Yes. In fact, delegates are encouraged to bring a musical instrument if they play one.
Electronic devices are permitted but may not be used during any sessions for any purpose
other then those approved by the session staff.
What should not be brought to the workshops?
1. Alcoholic beverages or drugs.
2. Valuable jewelry
3. A bad attitude.
Do delegates need to bring a coat and tie or nice dress for a special event?
No. It is highly recommended that shorts be worn as often as possible however long pants
(jeans) are recommended for Wednesday and Thursday nights. Please remind all delegates
that the dress code of the School Board of Broward County will be enforced and delegates
should pack accordingly.
Is there a “high ropes course” for delegates at SFLTC or Camp Eagle?
There will be a half-day of “high ropes” or “physical” leadership learning for Camp Eagle
delegates only. On Tuesday night delegates to SFLTC will experience a “low ropes”
course.
What is a “ropes course”?
An outdoor/indoor event similar to an obstacle course where teamwork is a must.
Must a delegate participate in “physical” activities?
No, while you will want to participate, the key phrase in any “ropes” learning experience,
low level or not is challenge by choice. A delegate will always have the opportunity to “sit
this one out”.
Is any special clothing required for either outdoor or indoor physical
activity?
Not really, but you must bring an extra set of “gym clothes” including “tennis shoes” to
participate. The “high ropes” will take place outside at the Broward College ropes facility.
The SFLTC Tuesday night activity will take place in the NSU Gym.
How do delegates sign up?
Each delegate must complete the appropriate paperwork for the camp they plan to attend.
Remember: SFLTC is for “first time” campers and Camp Eagle is for “returnees” or
delegates who have successfully completed a camp similar to SFLTC.
How can I get permission to participate in the Challenge Course
activities?
This booklet contains the special liability release permission form for Broward College’s
Tigertail Lake Challenge Course and must be returned with the SFLTC/Camp Eagle Parent
Permission Forms.
7
Do delegates need parental permission forms?
Yes, every delegate must submit signed copies of the parent permission and medical
information forms that are included in this packet.
Do delegates have to have an advisor attend with them?
No. Advisors are encouraged to attend but not required. Those who do attend must register
as a delegate just as the students.
Who may attend?
Students from any high school in the state of Florida may attend. However, no seniors who
graduated this year (16-17) and no returnees may attend SFLTC. Delegates who have
completed SFLTC (returnees) or a “like” camp may attend Camp Eagle. Preference
should be given to student government, class, and club officers who will be serving during
the 2017-2018 school year. No more than 240 students from throughout the state will be
accepted to attend SFLTC. The maximum number of delegates for Camp Eagle is sixty(60).
What about early departure/temporary dismissal?
Early departure is discouraged. Roommates are assigned, meals are ordered, and sessions
are planned on the basis of all registered delegates being in attendance for the entire
workshop. Schools should only send delegates who commit to attend the entire workshop.
Can students who previously attended SFLTC last year return to SFLTC?
No. They must attend Camp Eagle.
Can “first time” students attend Camp Eagle?
No. They must attend SFLTC
How many delegates can each school send?
Five (5) per camp, however, each school may complete the camp “waiting list” section of
the registration form, once the statewide registration deadline has passed, schools with
“waiting list” delegates will be contacted on a first come first serve basis.
What is the registration fee, to whom are checks made payable, and what
is the registration deadline?
The registration cost is $385.00 per delegate and all checks must be made payable to:
SBBC-Student Activities. Note: The fee for any delegates on the “Waiting List” should
not be included. “Waiting List” delegate fee of $385.00 and paperwork should be
forwarded upon notification. There are some special financial arrangements for Broward
County traditional schools.
The deadline for registration is May 12, 2017. Checks, completed registration forms,
permission forms and medical information forms should be sent to:
Pompano Administration Center.
Attn: Student Activities
610 NE 13 Ave.
Pompano Beach, FL 33060
8
What about refunds?
No refunds will be made after June 2, 2017.
Can substitutions be made?
Yes. However, male for female or female for male substitutions must have all the
appropriate paperwork turned in no later than 3pm Thursday, June 22, 2017. Same sex
substitutions may be made through 3pm, Thursday, July 6, 2017, and the substitute must
bring all necessary permission forms with them to camp. There is no charge for
substitutions.
Who can provide additional information about the SFLTC/Camp Eagle?
Additional information for both camps can be obtained by writing or call the Department of
Student Activities of the School Board of Broward County, FL. The office telephone
number is (754) 321-1201.
9
THE SCHOOL BOARD OF BROWARD COUNTY, FLORIDA
DRESS CODE
1.
Shoes must be worn at all times. For safety reasons, zoris, flipflops, thongs, and
bedroom slippers must not be worn.
2.
Clothing, mini-skirts or mini-dresses, halters, backless dresses, tube tops or tank that
exposes the torso or upper thighs (including “Sophies” and/or “Daisy Dukes” is not
allowed. Examples of clothing which may not be worn are: see-through garments
tops without overblouses or shirts, shirts or blouses tied at the midriff.
3.
Garments such as boxer shorts, bloomers, and bustiers, which were traditionally
designed as undergarments may not be worn as outer garments. Other clothing not
allowed are leggings without overblouses that reach mid thigh, tights, or hosiery
including those with lace trim, and bicycle racing attire unless underneath dresses,
skirts, or appropriate shorts. Appropriate t-shirts may be worn as outer garments.
4.
Students may wear hemmed shorts that are not shorter than mid-thigh including
walking shorts, Bermuda shorts, and split skirts (culottes). Athletic shorts are not
allowed.
5.
Students are not allowed to wear clothing, jewelry, buttons, haircuts, or other items
or markings which are offensive, suggestive, or indecent, associated with gangs,
encourage use of drugs, alcohol, or violence, or support discrimination on the basis
of age, color, handicap, national origin, marital status, race, religion, or sex.
6.
Head coverings including, but not limited to caps, hats, and bandanas are not
allowed unless they are required for safety programs such as home economics,
industrial arts, and vocational education, or are worn for bonafied religious or
medical reasons.
7.
Curlers and other hair grooming aids are not allowed. Personal grooming including,
but not limited to combing, brushing, spraying hair, and applying cosmetics are
allowed only in restrooms and or designated areas.
8.
Sunglasses may not be worn indoors unless a doctor’s permit is on file.
9.
Any articles of clothing or jewelry that may cause injury, such as belts or bracelets
with spikes are not allowed.
10
SFLTC SCHOOL REGISTRATION FORM (No Returnees)
_______________________________________________________________________
School Name
______________________________________________________________________________
Street Address
______________________________________________________________________________
City
Zip
______________________________________________________________________________
Telephone
______________________________________________________________________________
School Colors
Mascot
______________________________________________________________________________
Principal’s Name
______________________________________________________________________________
Student Council Advisor’s Name
Email: ___________________________
Telephone: _____________________________
_________________________________
Number of Female Student Delegates
_______________________________________
Number of Male Delegates
________________________________
Number of Female Adult Delegates
_______________________________________
Number of Male Adult Delegates
__________________________________
Total Number of Delegates
________________________________________
Amount of Check Enclosed
(Total # of Delegates is _____ x $385.00)
This form must be sent with the enrollment form
11
SFLTC DELEGATE ENROLLMENT FORM (No Returnees)
1. ______________________________________________________________________
Student Delegate
Sex
Shirt Size
Home Phone
______________________________________________________________________
Home Mailing Address
City
Zip
2. ______________________________________________________________________
Student Delegate
Sex
Shirt Size
Home Phone
_________________________________________________________________________
Home Mailing Address
City
Zip
3. ______________________________________________________________________
Student Delegate
Sex
Shirt Size
Home Phone
______________________________________________________________________
Home Mailing Address
City
Zip
4. ______________________________________________________________________
Student Delegate
Sex
Shirt Size
Home Phone
______________________________________________________________________
Home Mailing Address
City
Zip
5. ______________________________________________________________________
Student Delegate
Sex
Shirt Size
Home Phone
_____________________________________________________________________
Home Mailing Address
City
Zip
6. ______________________________________________________________________
Student Delegate
Sex
Shirt Size
Home Phone
______________________________________________________________________
Home Mailing Address
City
Zip
Waiting List Delegate (payment not to be included):
7. ______________________________________________________________________
Student Delegate
Sex
Shirt Size
Home Phone
______________________________________________________________________
Home Mailing Address
City
Zip
Adult Delegate:
______________________________________________________________________
Student Delegate
Sex
Shirt Size
Home Phone
______________________________________________________________________
Home Mailing Address
City
Zip
Principal:
___________________________________________________________________
Signature
Name
School Name
Applications must be signed by the Principal and the full registration fees for all delegates
must be enclosed. DUE May 12, 2017
12
SFLTC PARENT PERMISSION FORM (No Returnees)
I, the undersigned parent or legal guardian of, (please print or type child’s name) __________________________, a
student at _________________________High School, grant permission for my child to travel and to participate in the
South Florida Leadership Training Camp sponsored by the Student Activities Office of the Broward School District at
Nova Southeastern University in Davie, Florida, from Monday, July 17, 2017 through Friday, July 21, 2017. I
approve emergency treatment by a hospital and/or physician in the event of illness or injury and agree to assume
financial responsibility for bills incurred for such treatment. This permission form releases the School Board of
Broward County and members of the workshop staff from liability for injury, illness, or accident that may befall my
child while attending the workshop.
MEDIA RELEASE
I, the undersigned parent or legal guardian also grant South Florida Leadership Training Camp/School Board of
Broward County and persons acting for or through them, the rights to use, reproduce, assign, and/or distribute
photographs, films, videotapes, and sound recordings of my child, for use in any materials they may produce. I
understand that neither I, nor my child, will receive any compensation for such use of materials.
Parent/Legal Guardian Name: ___________________________________________________________
(Please print or type)
Parent/Legal Guardian Signature: ________________________________________________________
STUDENT INFORMATON
Does the student have a physical handicap
____Yes ____No.
________________________________________________________________________________
If yes, please explain.
Does the student have any allergies
____Yes ____No.
________________________________________________________________________________
If yes, please explain.
Does the student have a special diet?
____Yes ____No.
________________________________________________________________________________
If yes, please explain,
Is the student taking some type of medication
____Yes ____No.
________________________________________________________________________________
If yes, please explain. Note: All medications (prescription and over the counter) must be declared at camp check in.
Student Delegate Email Address: _________________________________________________________
Home Phone: ( ____) ____________________Work Phone: ( ____)______________________
Emergency Contact (not in immediate household):
Name: ____________________________________ Phone Number: (
__)___________________
Insurance Company: _________________________________Policy Number: ____________________
No Insurance Acceptance of Financial Responsibility
Parent/Legal Guardian Signature: ______________________________________________
13
(SFLTC)
TIGERTAIL LAKE CHALLENGE COURSE
LIABILITY RELEASE
I, the undersigned wish to voluntarily participate in the activity of the Challenge Course sponsored by Broward
College. This activity takes place beginning on July 18, 2016 and ends July 22, 2016. I understand the Broward
College Ropes Course teambuilding programs involve a variety of activities that often include games, group initiative
problems, low and high challenge course elements, initiatives involving water, and other rigorous physical activities,
including but not limited to running, lifting, bending, climbing, and sun exposure. It is recommended that participants
wear closed toe shoes and apply sunblock for outdoor activities. Certain health/medical information must be made
known to the instructor(s) conducting programs so that they are prepared to respond appropriately if the need arises.
This information will be held in confidence.
Challenge By Choice
Challenge course and team-building programs are composed of activities that may be unfamiliar to all participants. To
insure our participants’ control over their own personal safety, we have adopted the philosophy of “Challenge By
Choice.” At all times participants in Broward College Ropes Course activities are completely in control of their own
level of participation. You must listen carefully to all instructions and briefings, set your own goals free of the
influence of the group’s goals, make a decision as to your level of participation and inform others of your choice. No
one will force you to do anything; the choice is your own. However, you may perceive pressure to push yourself and
we encourage you to tell the group if this happens. During the program, we will provide a challenging setting in which
you can expand your limits, while supporting your personal boundaries.
I, the undersigned wish to participate in the activity of Broward College Tigertail Ropes Course. I affirmatively certify
that I am in good physical and mental health and that I am capable of participating in this program. I have read and
understand the above statement and I knowingly and willingly assume all risks and I knowingly and willingly hold
Broward College, the State of Florida, and any of their agents, contractors and employees harmless of any
responsibility should I suffer an injury, disability or death as a result of my participation in the above-mentioned
activity.
______________________________
Name of Participant (Print)
Student Under 18? _____Yes _____No
______________________________
Participant Signature
_______________
Date
______________________________
Co-Signature of Parent/ Guardian
(If student is under 18 years of age)
_______________
Date
580 Gulfstream Way
Dania Beach, Fl 33004
(954) 201-4500 Office
14
(954) 201-4506 Fax
CONFIDENTIAL PARTICIPATION HEALTH INFORMATION
Please print:
Name
Address
City
Phone (H)
Phone (W)
In case of emergency notify (name of Doctor)
Family or friend
Today’s date
Zip
Phone (other)
Phone
State
Phone
Medical History
No
Yes
Are you currently taking any medications that could impair your motor function, balance, alertness
and/or exposure to sun?
Describe
No
Yes
Describe
Have you been directed to carry an inhaler, Epi Kit, or other breathing device?
No
If so, is it with you now?
Yes
No
Yes
Describe
Do you have any allergies (including bee stings or any other insect bites)?
No
Yes
Are you pregnant? If yes, How many months?
No
Yes
Do you have physical or psychological limitations that may hinder your participation in today’s
activities?
Describe
______________________________
Participant Signature
__________________
Date
______________________________
Co-Signature of Parent/ Guardian
(If participant is under 18 years of age)
___________________
Date
PHOTO MEDIA RELEASE: I grant Broward College, Tigertail Lake Center the right to use, reproduce, assign and/or
distribute photographs, films, videotapes, and sounds recordings of myself for use in materials they may create.
Signature
580 Gulfstream Way
Date
Dania Beach, Fl 33004
(954) 201-4500 Office
15
(954) 201-4506 Fax
SFLTC/Camp Eagle
ARRIVAL FORM
STUDENT: ___________________________________________________
SCHOOL: ___________________________________________________
If you are traveling by train or bus, please complete Section A. If you are
traveling by air to Ft. Lauderdale Hollywood International Airport, please
complete Section B.
SECTION A:
ARRIVAL DATE: _____________
DEPARTURE DATE: ___________
______Ft. Lauderdale Bus Terminal
______Ft. Lauderdale Amtrack Station
______Ft. Lauderdale Tri-Rail Station
ARRIVAL TIME: _______AM PM
DEPARTURE TIME: _______AM PM
SECTION B:
ARRIVAL DATE: ______________
DEPARTURE DATE: _______________
ARRIVAL TIME: ______AM PM
DEPARTURE TIME: _________AM PM
AIRLINE: ______________________
AIRLINE: _________________________
FLIGHT NUMBER: ____________
NOTE: The camp staff will provide transportation from these stations for
students arriving prior to 1:00p.m. on Monday, July 17, 2017, and to these
stations for students departing after 9:30a.m. on Friday, July 21, 2017. (If
you encounter an issue at your arrival on pick up day call 954-249-6179)
16
CAMP EAGLE SCHOOL REGISTRATION FORM (no first timers)
_______________________________________________________________________
School Name
______________________________________________________________________________
Street Address
______________________________________________________________________________
City
Zip
______________________________________________________________________________
Telephone
______________________________________________________________________________
School Colors
Mascot
______________________________________________________________________________
Principal’s Name
______________________________________________________________________________
Student Council Advisor’s Name
Email: ___________________________
Telephone: _____________________________
_________________________________
Number of Female Student Delegates
_______________________________________
Number of Male Delegates
________________________________
Number of Female Adult Delegates
_______________________________________
Number of Male Adult Delegates
__________________________________
Total Number of Delegates
________________________________________
Amount of Check Enclosed
(Total # of Delegates is _____ x $385.00)
This form must be sent with the enrollment form.
Camp Eagle Delegate Enrollment Form (no first timers)
17
1. ______________________________________________________________________
Student Delegate
Sex
Shirt Size
Home Phone
______________________________________________________________________
Home Mailing Address
City
Zip
2. ______________________________________________________________________
Student Delegate
Sex
Shirt Size
Home Phone
_________________________________________________________________________
Home Mailing Address
City
Zip
3. ______________________________________________________________________
Student Delegate
Sex
Shirt Size
Home Phone
______________________________________________________________________
Home Mailing Address
City
Zip
4. ______________________________________________________________________
Student Delegate
Sex
Shirt Size
Home Phone
______________________________________________________________________
Home Mailing Address
City
Zip
5. ______________________________________________________________________
Student Delegate
Sex
Shirt Size
Home Phone
_____________________________________________________________________
Home Mailing Address
City
Zip
6. ______________________________________________________________________
Student Delegate
Sex
Shirt Size
Home Phone
______________________________________________________________________
Home Mailing Address
City
Zip
Waiting List Delegate (payment not to be included):
7. ______________________________________________________________________
Student Delegate
Sex
Shirt Size
Home Phone
______________________________________________________________________
Home Mailing Address
City
Zip
Adult Delegate:
______________________________________________________________________
Student Delegate
Sex
Shirt Size
Home Phone
______________________________________________________________________
Home Mailing Address
City
Zip
Principal:
____________________________________________________________________
Signature
Name
School Name
Applications must be signed by the Principal and the full registration fees for all delegates
must be enclosed. DUE May 12, 2017
CAMP EAGLE PARENT PERMISSION FORM (no first timers)
18
I, the undersigned parent or legal guardian of, (please print or type child’s name) __________________________, a student
at _________________________High School, grant permission for my child to travel and to participate in the Camp EagleAdvanced Leadership Training sponsored by the Student Activities Office of the Broward School District at Nova
Southeastern University in Davie, Florida, from Monday, July 17, 2017 through Friday, July 21, 2017. I approve
emergency treatment by a hospital and/or physician in the event of illness or injury and agree to assume financial
responsibility for bills incurred for such treatment. This permission form releases the School Board of Broward County and
members of the workshop staff from liability for injury, illness, or accident that may befall my child while attending the
workshop.
MEDIA RELEASE
I, the undersigned parent or legal guardian also grant South Florida Leadership Training Camp/School Board of Broward
County and persons acting for or through them, the rights to use, reproduce, assign, and/or distribute photographs, films,
videotapes, and sound recordings of my child, for use in any materials they may produce. I understand that neither I, nor my
child, will receive any compensation for such use of materials.
Parent/Legal Guardian Name: ___________________________________________________________
(Please print or type)
Parent/Legal Guardian Signature: ________________________________________________________
STUDENT INFORMATON
Does the student have a physical handicap
____Yes ____No.
________________________________________________________________________________
If yes, please explain.
Does the student have any allergies
____Yes ____No.
________________________________________________________________________________
If yes, please explain.
Does the student have a special diet?
____Yes ____No.
________________________________________________________________________________
If yes, please explain,
Is the student taking some type of medication
____Yes ____No.
________________________________________________________________________________
If yes, please explain. Note: All medications (prescription and over the counter) must be declared at camp check in.
Student Delegate Email Address: _________________________________________________________
Home Phone: ( ____) ____________________Work Phone: ( ____)______________________
Emergency Contact (not in immediate household):
Name: ____________________________________ Phone Number: (
__)___________________
Insurance Company: _________________________________Policy Number: ____________________
No Insurance Acceptance of Financial Responsibility
Parent/Legal Guardian Signature: ______________________________________________
(CAMP EAGLE)
19
TIGERTAIL LAKE CHALLENGE COURSE
LIABILITY RELEASE
I, the undersigned wish to voluntarily participate in the activity of the Challenge Course sponsored by Broward
College. This activity takes place beginning on July 18, 2016 and ends July 22, 2016. I understand the Broward
College Ropes Course teambuilding programs involve a variety of activities that often include games, group
initiative problems, low and high challenge course elements, initiatives involving water, and other rigorous
physical activities, including but not limited to running, lifting, bending, climbing, and sun exposure. It is
recommended that participants wear closed toe shoes and apply sunblock for outdoor activities. Certain
health/medical information must be made known to the instructor(s) conducting programs so that they are
prepared to respond appropriately if the need arises. This information will be held in confidence.
Challenge By Choice
Challenge course and team-building programs are composed of activities that may be unfamiliar to all
participants. To insure our participants’ control over their own personal safety, we have adopted the philosophy
of “Challenge By Choice.” At all times participants in Broward College Ropes Course activities are completely
in control of their own level of participation. You must listen carefully to all instructions and briefings, set your
own goals free of the influence of the group’s goals, make a decision as to your level of participation and inform
others of your choice. No one will force you to do anything; the choice is your own. However, you may
perceive pressure to push yourself and we encourage you to tell the group if this happens. During the program,
we will provide a challenging setting in which you can expand your limits, while supporting your personal
boundaries.
I, the undersigned wish to participate in the activity of Broward College Tigertail Ropes Course. I affirmatively
certify that I am in good physical and mental health and that I am capable of participating in this program. I have
read and understand the above statement and I knowingly and willingly assume all risks and I knowingly and
willingly hold Broward College, the State of Florida, and any of their agents, contractors and employees
harmless of any responsibility should I suffer an injury, disability or death as a result of my participation in the
above-mentioned activity.
_____________________________
Name of Participant (Print)
Student Under 18? _____Yes _____No
______________________________
Participant Signature
_______________
Date
______________________________
Co-Signature of Parent/ Guardian
(If student is under 18 years of age)
_______________
Date
580 Gulfstream Way
Dania Beach, Fl 33004
(954) 201-4500 Office
CONFIDENTIAL PARTICIPATION HEALTH INFORMATION
20
(954) 201-4506 Fax
Please print:
Name
Address
City
Phone (H)
Phone (W)
In case of emergency notify (name of Doctor)
Family or friend
Today’s date
State
Zip
Phone (other)
Phone
Phone
Medical History
No Yes
Are you currently taking any medications that could impair your motor function, balance, alertness
and/or exposure to sun?
Describe
No Yes
Have you been directed to carry an inhaler, Epi Kit, or other breathing device?
Describe
No Yes
If so, is it with you now?
No Yes
Do you have any allergies (including bee stings or any other insect bites)?
Describe
No Yes
Are you pregnant? If yes, How many months?
No Yes
Do you have physical or psychological limitations that may hinder your participation in today’s
activities?
Describe
______________________________
Participant Signature
__________________
Date
______________________________
Co-Signature of Parent/ Guardian
(If participant is under 18 years of age)
___________________
Date
PHOTO MEDIA RELEASE: I grant Broward College, Tigertail Lake Center the right to use, reproduce, assign
and/or distribute photographs, films, videotapes, and sounds recordings of myself for use in materials they may
create.
Signature
580 Gulfstream Way
Date
Dania Beach, Fl 33004
(954) 201-4500 Office
21
(954) 201-4506 Fax
The Commons
22
Special Thanks
to
The School Board of Broward County, Florida
Chairperson: Dr. Rosalind Osgood
Vice Chairperson: Abby M. Freedman
Robin Bartleman
Heather P. Brinkworth
Patricia Good
Donna P. Korn
Laurie Rich Levinson
Ann Murray
Nora Rupert
And
Robert W. Runcie
Superintendent of Schools
23