FPSL Application

Future Public Service Leaders- 2026

Application to participate in the June 22-26, 2026 Future Public Service Leaders camp.

Parent/Guardian Information

Name

First Name

Last Name

Email

Cell Phone

Address (if different than student's address)

City

State/Province

Zip/Postal

Emergency Contacts & Insurance

Primary people to be notified in case of emergency.

Emergency Contact 1 Name

Relationship

Contact 1 Phone

Emergency Contact 2 Name

Relationship

Contact 2 Phone

Family Physician

Physician Phone

Insurance Provider

Policy Number

Insurance Phone

Insurance Subscriber Name

Subscriber date of birth

I understand that UAB does not offer any form of health, liability, or other insurance coverage for participants.

Initial above.

Medical Information and Liability Waiver

Are all immunizations up to date?

Yes

No

Date of last tetanus shot

Please list any current medical concerns or medical history we need to know about your child (e.g., past injuries, current conditions, physical limitations, etc.) or N/A:

List any allergies (ex: medications, bee stings, food, latex, plants, etc.), or "N/A"

Does your child have a disability that requires reasonable accommodations to enable them to participate in the program?

Yes

No

To Request Reasonable Accommodations...

Please provide any additional information that you feel could be relevant or beneficial for our staff to know in supporting your student during this program, or N/A:

Will medication need to be taken DURING the program (9am-4pm)?

No

Yes

Medication Management Form

Yes, I agree to submit the form when it is emailed to me

In order for my child to take medicine during the program, I understand that I must submit a Medication Management Form prior to my child attending camp.

The following person/people will normally drop off/pick up my child. List the name, relationship to child, and cell phone number. If your child will drive themselves, please note that parking is not provided, but there is a public parking deck (~$12/day) within 2 blocks.

To Complete Enrollment

I understand that to finish enrollment, I will need to submit: 1. A copy of my insurance card (front and back); 2. A signed Student Code of Conduct; 3. Authorization for Medical Care; 4. Liability waiver; 5. Medication management form (only if medication needs to be taken during the program)

Please send me the forms via email

Please send me the printed forms via mail

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