2017 ASM Materials Day Camp Registration
Register on or before June 9th for this free Materials Camp to be held at Black Hawk Community College, Moline, IL, on June 13-15, 2017. Class size is limited to 18 sophomore, junior or senior year students. If you have questions, contact Bob Gaster at 563-340-8862 or by email at bgaster5280@gmail.com OR Cynthia Krist, Arconic Davenport Works at 563-459-2516 or by email at Cynthia.Krist@arconic.com. Thanks for your interest in the Camp. When you have successfully completed the form, you should see a screen notifying you "Your response has been recorded". Please note: ALL fields are required fields (*). Upon your confirmed registration Camp details will be sent the week before Camp.
Email address
Student First Name
Your answer
Student Last Name
Your answer
Email Address
Your answer
T-Shirt Size (Materials Camp Shirt Provided at no cost)
Year in School
Grade in Fall 2017
9-Digit Phone Number
area code - xxx - xxxx
Your answer
School
Your answer
Home Street Address
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
US Citizenship
Need to know in advance for the planned tours.
Mother/Father/Guardian Name
Relationship (e.g. Mother) + First and Last name
Your answer
Mother/Father/Guardian Home Phone
area code - xxx - xxxx
Your answer
Mother/Father/Guardian Cell or Work Phone for Emergency Daytime Contact
area code - xxx - xxxx
Your answer
Other Emergency Contact Name
Relationship (e.g. uncle) + First and Last Name
Your answer
Emergency Contact Phone
area code - xxx - xxxx
Your answer
Medical Information: Known Allergies
No/Yes - Please explain if "Yes"
Your answer
Medical Information: Medications
Will the student require regular medications during the camp? No/Yes - Please explain if "Yes"
Your answer
Medical Information: Chronic Conditions (for hands on lab work)
Are there any physical disabilities or chronic conditions that should be known for the student to safely participate? - Yes/No - Please explain if yes
Your answer
Release and Consent - Parent/Legal Guardian First/Last Name - Date (MM/DD/YY)
1) I grant full permission to use photographs, videos, recordings and other records of this event for the purpose of promoting engineering and future engineer camps. 2) Should an accident requiring medical care occur, I give full consent to a licensed physician to provide whatever care is needed. And I authorize my student to be transported for medical attention if I cannot be reached. 3) By signing below I give full consent for my student to participate in the Materials Engineering Day Camp and agree to relieve the Quad Cities Chapter of ASM, Black Hawk College, its volunteers and its sponsors of all liability related to the camp.
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