05142014 dist mmi_stem_registration_packet-2014

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05142014 dist mmi_stem_registration_packet-2014

  1. 1. P a g e | 1 2014 Summer STEM Academy Registration Form To register for the HCC Summer STEM Academy, please complete and return to your school counselor, or teacher. For additional information, please call John Gilmore III at (713) 718-5061 or by e-mail at John.gilmoreiii@hccs.edu. Academy Scholar Information: Scholar Name: PLEASE PRINT LEGABLY Student Last Name Student First Name Middle School Attending (Fall Semester): Grade (Fall Semester): Date of Birth: _______________ Age: _________ SS# :_____/____/______( Last 4 digits) Gender: ⃝Male ⃝ Female Ethnicity: Black ⃝ Hispanic ⃝ Indian ⃝ Asian ⃝ White ⃝ Native American ⃝ Home Address: Street Apt. No. City Zip Code Parent Information: Father’s Last Name First Name Middle Initial Home Phone: ______________________ Cell Phone: _____________________ E-Mail Address: __________________________________________________________ Mother’s Last Name First Name Middle Initial Home Phone: ______________________ Cell Phone: _____________________ E-Mail Address: Student lives with (check applicable): ⃝ Mother ⃝ Father ⃝ other:
  2. 2. P a g e | 2 Questionnaire: 1. Have you attended HCC STEM Academy before? Yes ⃝ No ⃝ 2. How many years? _______ 3. Which year did you attend the STEM Academy? 2010 ⃝ 2011 ⃝ 2012 ⃝ 2013 ⃝ 4. Have you taken Algebra? Yes ⃝ No ⃝ 5. What level of Algebra have you taken? (If not applicable reply N/A) _____________________________________________ How did you hear about the HCC Summer STEM Academy? (Check one below) School ⃝ Friend ⃝ Flyer ⃝Website ⃝ other ⃝ (please specify): Check Shirt Size: Small ⃝ Medium ⃝ Large ⃝ X-Large ⃝ XX-Large ⃝
  3. 3. P a g e | 3 Information and Authorization Form Scholar’s Last Name: ________________________ First Name: ________________________ Date of Birth: __________ Age: ____ Father’s Last Name: ____________________________ First Name: ________________________ Phone Number: (___) ________________ Alternate Phone Number: (____) _________________ Mother’s Last Name: _______________________ First Name: ________________________ Phone Number: (___) ________________ Alternate Phone Number: (____) _________________ Emergency Contact Name: ______________________________ Phone Number (____) ______________ Authorized Adult: ______________________________________ Phone Number (____) _______________ Authorized Adult: ______________________________________ Phone Number (____) _______________ Medication Form on File: Yes No N/A Parent/ Guardian Signature: ____________________________________ Date: ________________ A Parent, Guardian, or Authorized Adult must sign for each child in/out of camp every morning and afternoon. The only people that your child will be released to are those listed on your information form. Note: All persons authorized to pick up campers must be at least 16 years of age. If someone other than the parent will pick up your child, please give us prior written notice. If there is an emergency and no one on your list can pick up your child, the Primary Parent/Guardian must Fax a letter and Copy your Drivers Licenses on the letter to allow another adult to pick up the child. Everyone authorized to sign-out a child must present a valid U. S. Drivers Licenses or State Identification. No Exceptions. I hereby waive any claims or causes of action which I may now or hereafter have against HCC STEM ACADEMY arising out of my child’s participation. I will indemnify and hold harmless against any and all claims resulting from such participation. In the event my child should sustain injuries or illness while involved in the HCC STEM ACADEMY, I hereby authorize such aid or other treatment as may be necessary under the circumstances, to include treatment by a physician or hospital.
  4. 4. P a g e | 4 I, the model, hereby grant Houston Community College permission to make still photographs, video tapes, audio recordings and/or use of verbal quotes from me. I also give Houston Community College permission to use these completed audiovisual and print products for Houston Community College promotional purposes without compensation or remuneration to me in any manner; in like and related regard, HCC will not charge or assess me any fees or service charges for my voluntary participation in this audiovisual product production. Further, I relinquish and give to the Houston Community College all rights, title and interest, if any, I may have in the completed video tapes, still photographs or audio recordings, negative, prints, reproductions and copies of the masters, negatives, recordings, duplicates, prints and verbal quotes for print. Witness our hands and concurrence to the above terms: __________________________________ __________________________________ Signature (Model) Address __________________________________ __________________________________ Signature of Parent/Guardian if Minor Phone Date
  5. 5. P a g e | 5 Distinctive Instructions / Medication Information Scholar’s Last Name: ________________________ First Name: ________________________ Date of Birth: __________ Age: ____ Father’s Last Name: ____________________________ First Name: ________________________ Phone Number: (___) ________________ Alternate Phone Number: (____) _________________ Mother’s Last Name: _______________________ First Name: ________________________ Phone Number: (___) ________________ Alternate Phone Number: (____) _________________ Emergency Contact Name: ______________________________ Phone Number (____) ______________ Emergency Contact Name: ______________________________ Phone Number (____) ______________ Authorized Adult: ______________________________________ Phone Number (____) ______________ Authorized Adult: ______________________________________ Phone Number (____) ______________ Authorized Adult: ______________________________________ Phone Number (____) ______________ Special Instructions, Allergies, or Diets: ____________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ Parent/ Guardian Signature: ____________________________________ Date: ________________ I hereby waive any claims or causes of action which I may now or hereafter have against HCC STEM ACADEMY arising out of my child’s participation. I will indemnify and hold harmless against any and all claims resulting from such participation, In the event my child should sustain injuries or illness while involved in the HCC STEM ACADEMY, I hereby authorize such aid or other treatment as may be necessary under the circumstances, to include treatment by a physician or hospital.
  6. 6. P a g e | 6 Car Rider Information Scholar’s Last Name: ________________________ First Name: ________________________ Date of Birth: __________ Age: ____ Father’s Last Name: ____________________________ First Name: ________________________ Phone Number: (___) ________________ Alternate Phone Number: (____) _________________ Mother’s Last Name: _______________________ First Name: ________________________ Phone Number: (___) ________________ Alternate Phone Number: (____) _________________ Emergency Contact Name: ______________________________ Phone Number (____) ______________ Authorized Adult: ______________________________________ Phone Number (____) _____________ Authorized Adult: ______________________________________ Phone Number (____) _____________ Authorized Adult: ______________________________________ Phone Number (____) _____________ Authorized Adult: ______________________________________ Phone Number (____) _____________ Authorized Adult: ______________________________________ Phone Number (____) _____________ Special Instructions, Allergies, or Diets: ____________________________________________________ ____________________________________________________________________________________ Parent/ Guardian Signature: ____________________________________ Date: ________________ A Parent, Guardian, or Authorized Adult must sign for each child in/out of camp every morning and afternoon. The only people that your child will be released to are those listed on your information form. Note: All persons authorized to pick up campers must be at least 16 years of age. If someone other than the parent will pick up your child, please give us prior written notice. If there is an emergency and no one on your list can pick up your child, the Primary Parent/Guardian must Fax a letter and Copy your Drivers Licenses on the letter to allow another adult to pick up the child. Everyone authorized to sign-out a child must present a valid U. S. Drivers Licenses or State Identification. No Exceptions. I hereby waive any claims or causes of action which I may now or hereafter have against HCC STEM ACADEMY arising out of my child’s participation. I will indemnify and hold harmless against any and all claims resulting from such participation, In the event my child should sustain injuries or illness while involved in the HCC STEM ACADEMY, I hereby authorize such aid or other treatment as may be necessary under the circumstances, to include treatment by a physician or hospital.
  7. 7. P a g e | 7 Bus Rider Information Scholar’s Last Name: ________________________ First Name: ________________________ Date of Birth: __________ Age: ____ Father’s Last Name: ____________________________ First Name: ________________________ Phone Number: (___) ________________ Alternate Phone Number: (____) _________________ Mother’s Last Name: _______________________ First Name: ________________________ Phone Number: (___) ________________ Alternate Phone Number: (____) _________________ Emergency Contact Name: ______________________________ Phone Number (____) ______________ Authorized Adult: ______________________________________ Phone Number (____) _____________ Authorized Adult: ______________________________________ Phone Number (____) _____________ Authorized Adult: ______________________________________ Phone Number (____) _____________ Authorized Adult: ______________________________________ Phone Number (____) _____________ Authorized Adult: ______________________________________ Phone Number (____) _____________ Special Instructions, Allergies, or Diets: ____________________________________________________ ____________________________________________________________________________________ Parent/ Guardian Signature: ____________________________________ Date: ________________ A Parent, Guardian, or Authorized Adult must sign for each child in/out of camp every morning and afternoon. The only people that your child will be released to are those listed on your information form. Note: All persons authorized to pick up campers must be at least 16 years of age. If someone other than the parent will pick up your child, please give us prior written notice. If there is an emergency and no one on your list can pick up your child, the Primary Parent/Guardian must Fax a letter and Copy your Drivers Licenses on the letter to allow another adult to pick up the child. Everyone authorized to sign-out a child must present a valid U. S. Drivers Licenses or State Identification. No Exceptions. I hereby waive any claims or causes of action which I may now or hereafter have against HCC STEM ACADEMY arising out of my child’s participation. I will indemnify and hold harmless against any and all claims resulting from such participation, In the event my child should sustain injuries or illness while involved in the HCC STEM ACADEMY, I hereby authorize such aid or other treatment as may be necessary under the circumstances, to include treatment by a physician or hospital.
  8. 8. P a g e | 8 Walker Information Scholar’s Last Name: ________________________ First Name: ________________________ Date of Birth: __________ Age: ____ Father’s Last Name: ____________________________ First Name: ________________________ Phone Number: (___) ________________ Alternate Phone Number: (____) _________________ Mother’s Last Name: _______________________ First Name: ________________________ Phone Number: (___) ________________ Alternate Phone Number: (____) _________________ Emergency Contact Name: _______________________________ Phone Number (____) _____________ Authorized Adult: _______________________________________ Phone Number (____) _____________ Authorized Adult: _______________________________________ Phone Number (____) _____________ Authorized Adult: ________________________________________ Phone Number (____) ___________ Authorized Adult: _______________________________________ Phone Number (____) ____________ Authorized Adult: _______________________________________ Phone Number (____) ____________ Special Instructions, Allergies, or Diets: ____________________________________________________ ____________________________________________________________________________________ Parent/ Guardian Signature: ____________________________________ Date: ________________ A Parent, Guardian, or Authorized Adult must sign for each child in/out of camp every morning and afternoon. The only people that your child will be released to are those listed on your information form. Note: All persons authorized to pick up campers must be at least 16 years of age. If someone other than the parent will pick up your child, please give us prior written notice. If there is an emergency and no one on your list can pick up your child, the Primary Parent/Guardian must Fax a letter and Copy your Drivers Licenses on the letter to allow another adult to pick up the child. Everyone authorized to sign-out a child must present a valid U. S. Drivers Licenses or State Identification. No Exceptions. I hereby waive any claims or causes of action which I may now or hereafter have against HCC STEM ACADEMY arising out of my child’s participation. I will indemnify and hold harmless against any and all claims resulting from such participation, In the event my child should sustain injuries or illness while involved in the HCC STEM ACADEMY, I hereby authorize such aid or other treatment as may be necessary under the circumstances, to include treatment by a physician or hospital.

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