APPLICATION : Design, Engineering, & Manufacturing Summer Camp
Deadline to complete application is April 30,2019

First Year Student Camp to be held June 3-6, 2019; Returning Student Camp to be held June 4-7, 2019

Camp location: Northwest Georgia College & Career Academy, 2300 Maddox Chapel Road, Dalton
Camp Hours: 8:30am-4:00pm; Campers may be dropped off at school beginning at 7:45am (breakfast is available)

Email address *
Camper's First Name:
Your answer
Camper's Last Name:
Your answer
Name of School to be attending August 2019:
School grade the camper will be entering in August 2019
Is the student a returning camper?
Date of Birth:
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Gender:
Ethnicity?
Your answer
Is the camper a current member of the Dalton Boys and Girls Club?
If a current member of the Boys and Girls club, is transportation needed from the Dalton Club location to DEM Camp?
Medical Information:
Doctor's Name: *
Your answer
Doctor's Phone: *
Your answer
Permission for treatment by doctor / hospital if necessary during camp? *
Does your family have health and/or accident insurance? *
Insurance Company:
Your answer
Policy Number:
Your answer
Does the Camper have any special dietary needs or food allergies? If yes, please explain. *
Allergy Explanation
Your answer
Parent Permission
Parent/Guardian Name:
Your answer
Email:
Your answer
Home Address:
Your answer
Cell Phone Number:
Your answer
Home or Work Phone Number:
Your answer
Alternate Emergency Contact Name:
Your answer
Alternate Contact’s Cell Phone Number:
Your answer
My child may participate in all activities associated with the Design, Engineering, & Manufacturing Summer Camp including associated industrial tours conducted during the camp.
DISCLAIMER:
I hereby give my son/daughter permission to attend and participate in the Design, Engineering, & Manufacturing Summer Camp presented by the Boys & Girls Club and area sponsors/businesses. By signing below, I certify the information provided in this form, medical and otherwise, is true to the best of my knowledge. I authorize Boys & Girls Clubs of Gordon, Murray, & Whitfield Counties (GMW) or camp administrators to contact me if my child is injured and/or harmed in any way. I also authorize Boys & Girls Clubs of GMW or camp administrators to seek medical attention for my child if he or she is injured and/or harmed and needs immediate medical assistance at a local hospital or emergency care center. I certify that I and/or our family’s insurance provider will be responsible for any financial medical costs that may be associated with all medical attention and treatment given to my child. In consideration of their granting my child the opportunity to participate in this Boys & Girls Clubs of GMW Program, and being transported in Boys & Girls Club of GMW vehicles, I hereby release, indemnify and hold harmless the Department of Human Resources, Boys & Girls Clubs of GMW, Whitfield County Schools and camp sponsors from any liability, claim or demand resulting from any legal medical attention and assistance that may be needed and provided as a result of an injury or harmful incident to my child. If the Parent or Guardian does file a complaint against the Georgia DHR or the Club the Parent or Guardian agrees to pay for all DHR & Boys & Girls Clubs of GMW Counties’ legal fees.
PERMISSION TO TRANSPORT:
I hereby give permission for my child to be transported to and from any program affiliated with the programs and activities associated or affiliated with the Design, Engineering, & Manufacturing Summer Camp. I hereby release all sponsor & presenter organizations, their employees, associates, and contributors from liability from
any injury, loss or theft incurred by my son/daughter in the course of this transportation.
PERMISSION TO PHOTOGRAPH & VIDEO:
Photographs and videos of students may be taken during the camp for use in official marketing materials, newspaper articles, school publications, website advertising, sponsor publications/websites, etc. I agree to release and hold harmless the sponsoring and presenting organizations from and against any claims, damages, action, liability, and expense in connection with the use of my child’s image. Parents who do not wish to have their children’s images used must file a written request with the Boys & Girls Club prior to the first day of the camp.
My printed name indicates that I completely understand the above statements.
Parent/Guardian Printed Name: *
Your answer
Date *
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