Youth Igniting Change Summer Institute: Amplify Your Voice Registration
When: June 12 - 16th // 9am-2pm, except Friday ends at 12pm with a presentation
Where: JMU's Ice House Building // 127 West Bruce St.
Who: Rising 9th-12th Graders
Cost: Free!
Student's First Name:
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Student's Last Name:
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Date of Birth: (mm/dd/yy)
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Gender
Age
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Grade for 2017-2018 School Year
Required
What School do you Attend?
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Mother or Guardian: Name/Phone number/Email Address
Your answer
Father or Guardian: Name/Phone Number/Email Address
Your answer
Current Address: Street/City/State/Zip Code
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Do you need transportation to camp? (Rides available to students in Harrisonburg & Rockingham County)
Medical and Media Release Agreement
The child registered on this form has permission to participate in the Office on Children and Youth's summer institute. I agree that the Office on Children and Youth and James Madison University will not be held responsible for accidents arising thereof. I am responsible for any medical obligations incurred during these summer institute activities and give the summer institute permission to seek treatment in case of injury or illness. I understand that I am ultimately responsible for my child’s behavior at camp and that they will be expected to sign and live by the camp agreement which states: “I will respect myself and my peers.”
Insurance Company (if none, please indicate as n/a)
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Insurance Policy # (if none, please indicate as n/a)
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Insurance Company Phone # (if none, please indicate as n/a)
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Doctor's Name
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Doctor's Phone #
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Allergies or Dietary Restrictions:
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Emergency Contact if parent or guardian cannot be reached
Name/Relationship to Student/Phone number (daytime or cell phone number)
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