2016 Charge Into STEM  Summer Camp Registration
Please contact sparky@the-charge.com with questions.
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Name of Camper *
Camper's Grade *
What grade level will they enter in the fall?
School Camper currently attends
Camper's T-Shirt Size *
Select one
Parent/Guardian Name *
Your address *
Street, City, Zip Code
Phone Number *
Best # to reach you
Your email address *
Names (first and last) of other adults authorized to pick up your camper
Separate by comma
Additional Emergency Contacts (if parent/guardian cannot be reached)
Give Name and Phone number
MEDICAL INFORMATION
Please list all known conditions. If there are none, write "none" in the response box.
Your Camper will be doing hands-on activities in small groups with other elementary students and a high school camp counselor. Does your Camper have any medical conditions, allergies, or special needs of which our high school aged staff needs to be made aware? *
Is your Camper taking any medications or will he/she need to take anything while at camp? *
Medications will need to be labeled clearly and given to an adult counselor at drop off.
Are there any activities from which your Camper should be restricted? *
OTHER INFORMATION
Is there anything else you would like for us to know?
How did you hear about our STEM Camp? *
PARENTAL CONSENT & CAMPER PHOTO RELEASE APPROVAL
By checking this box you agree that you are the parent or legal guardian of the named Camper, are over the age of 18, AND: *
As parent/guardian, I authorize treatment of my Camper under the direction of any licensed medical professional in the event of a medical emergency which, in the opinion of the attending adult camp personnel, may endanger his/her life, cause disfigurement, physical impairment, or undue discomfort if delayed.  This authority is granted only after a reasonable effort has been made to reach me by phone at the number(s) listed.  I assume responsibility for any costs connected with such treatment and release the school district, the mentors, chaperones, TEAM 2619, and/or the activities staff responsible for any liability.   I understand that the named Camper will only be released to the authorized adults listed on this form.    I give permission for any photography or video taken of my Camper during camp to be used by Team 2619, The Charge, on their social media sites and as part of community outreach advertising.
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