2018 ASM Materials Day Camp Registration
Register on or before May 29th for this free Materials Camp to be held at Black Hawk Community College, Moline, IL, on June 5-7, 2018. Class size is limited to 21 sophomore, junior or senior year high school 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 2018
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.
Your answer
A copy of your responses will be emailed to the address you provided.
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