2017 Middle School Camp
Three week-long camps for rising 6th, 7th, 8th, and 9th graders. Each session is Monday - Friday from 9:00 am - 4:00 pm at Michigan Tech's Great Lakes Research Center in Houghton. Attend one, two, or all three camps! Lunch is provided. Class size is limited to 20 participants.
Student Name *
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Student is:
Middle School Sessions *
Select one, two, or three weeks!
Required
Parent/Guardian Name *
Your answer
Parent/Guardian Email *
Your answer
Parent/Guardian Phone Number *
Your answer
Which school does your child attend? *
Your answer
Which grade will your child be entering in the fall? *
Address *
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Is this your child's first time attending a Center for Science and Environmental Outreach after-school class or camp at Michigan Tech?
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.
Your answer
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.
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How did you hear about our program?
Please read the following liability release, parental consent and photo release. Indicate your acceptance by initialing below.
LIABILITY RELEASE AND PARENTAL CONSENT ~ Michigan Technological University (“the University”) requires that all participants or their parents/guardians in the MTU Summer Science Camp program for students, taught by the Center for Science & Environmental Outreach or Western Upper Peninsula Center for Science, Mathematics & Environmental Education (“the Center”) 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, ASSUMPTION OF RISK ~ The undersigned participant, or parent or guardian of a minor participant, understands 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 my child will (if signing as a parent or guardian) follow all safety instructions and ask questions if he/she does not understand. In consideration of the acceptance of myself or the minor as a participant in the 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 during the course or as a result of their participation. I do hereby fully and forever release and discharge, covenant not to sue and agree to indemnify and hold harmless the Center for Science & Environmental Outreach, 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.
PHOTO RELEASE ~ 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.
I have read the above and agree.
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