Summer Science Camp 2015
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Student Name *
Your child is:
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Please make a selection below for children:
Sessions are June 16-18 Tues, Wed., & Thur. from 9:00 am - 4:00 pm
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Parent/Guardian Name *
Parent/Guardian Email *
Parent/Guardian Phone Number *
Which school does your child attend? *
What grade will your child be entering in the fall? *
Address *
Is this your child's first time attending a Center for Science and Environmental Outreach program through Michigan Tech?
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Person(s) authorized to pick up your child/Emergency contact *
Please list all people who may potentially pick up your child along with their phone number and relationship to the student.
Please list any medical conditions along with medications associated with your child (bee/peanut/shellfish allergies, asthma, diabetes, etc.). *
If your child has an inhaler, epi-pen, or insulin injections, please specify.
Does the Center for Science and Environmental Outreach and Michigan Tech have permission to use photos of your child in educational or promotional materials? *
I/We the above participants, and parents/guardians, do hereby consent to participation in the above program, and all activities which are part of the program.  I/We assume all responsibilities for, and risks and hazards of, participation in the named program.  I/We understand that NO REFUNDS  will be issued. *
By giving your initials below, you are agreeing to the terms listed above.  Please initial and date the space below.
How did you hear about our program?
LIABILITY RELEASE AND PARENTAL CONSENT ~ MTU Summer Science Camp  Michigan Technological University (“the University”) and the Center for Science & Environmental Outreach / Western Upper Peninsula Center for Science, Mathematics & Environmental Education  (“the Center”)  Students, educators and chaperones participating in the Michigan Tech Summer Science Camp programs must sign and submit this LIABILITY RELEASE AND PARENTAL CONSENT form.  Participants will engage in a variety of educational programs led by Michigan Tech faculty, staff and students that may be at the Great Lakes Research Center, on the Michigan Tech Campus, aboard the Agassiz research vessel, at the Nara Nature Center, and/or on field trips.  Consent, Waiver, Release and Assumption of Risk  I, the undersigned participant, or parent or guardian of a minor participant, understand that there are inherent risks associated with this activity that cannot be eliminated, and that each participant must assume the risk of injury or disabilities that could result. I hereby acknowledge that I am aware of these risks and I agree that I will, or if signing as a parent or guardian,t to, follow all safety instructions and ask questions if I or they do not understand.  In consideration of the acceptance of myself or the minor as a participant in the Ride the Waves program, I assume the risk of and full responsibility for any bodily injuries, death, damages or expenses to me or the minor for whom I am signing which may occur in the course of or as a result of my or their participation.  I do hereby fully and forever release and discharge, covenant not to sue and agree to indemnify and hold harmless the Western Upper Peninsula Center for Science, Mathematics & Environmental Education, and Michigan Technological University and its Board of Control, employees, and agents from and against any and all claims, demands, damages or rights of action due to bodily injury, death, or property damage, present or future, whether the same be known or unknown, anticipated or unanticipated, resulting from or arising out of my participation or the minor’s participation in the Michigan Tech Summer Science Camp and all related activities and tours.   I hereby further consent to and authorize the University, Center staff or program leader(s) to obtain whatever medical treatment and/or care is deemed necessary by such staff for the health and well-being of myself or the participant during the term of program participation, including the consent to obtain and have administered any emergency medical or surgical treatment.   The University and/or the Center reserves the right to use any pictures taken during the program for advertising and/or instructional purposes.   I have read the foregoing, explained its meaning to my child or ward if the participant is a minor, and hereby do approve and consent to the terms and conditions stated. If the participant is a minor I consent to the participation of my child in the Michigan Tech Summer Science Camp and all related activities and tours.  In lieu of the signature of a Parent/Guardian, please type your name in the box provided below. Thank you.
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