It's that time of year again! The summer is almost here and I know that many of you are in the midst of planning out your summer camp schedule for your children. Our annual STARBASE Science Tech/Engineering Camp, in collaboration with Peach State STARBASE, is scheduled for July 22-25th at Dobbins ARB/Bldg. 935. Attached are the necessary forms to enroll in the camp. Please see details below: Ages: 10-12 years old Date: Monday, July 22-Thursday, July 25, 2013 Time: 0900-1500 Location: Dobbins ARB/BLDG 935 (Starbase Building) Cost: $50.00 (checks made out to Peach State Starbase Foundation) Registration Deadline: Friday, June 14, 2013 LUNCH IS INCLUDED! **CAMP IS OPEN TO DEPENDENTS OF GA NATIONAL GUARD SERVICE MEMBERS (ARMY & AIR), AIR FORCE RESERVE, & DOD EMPLOYEES** There are a limited number of slots available. If you are interested, I would encourage you to submit the registration forms as soon as possible. Thank you and have a great day! Kara B. Coleman, MSW, LCSW Child & Youth Services Director Georgia National Guard Family Program Office CNGC 1000 Halsey Avenue, BLDG 447 840 Finch Marietta, GA 30060 Office: 678-569-5860 Cellular: 404-308-2208 Fax: 678-569-3910 www. GeorgiaGuardFamilyProgram.org/youth

1. July 22-25, 2013

2. July 22-25, 2013
STUDENT APPLICATION/PERMISSION FORM
Please print clearly – Due by Friday, June 14, 2013
Child's Name___________________________________________ Female___
Male ___
Street
Address__________________________________________________________
City___________________________________________ State_______
Zip__________
Parent's
Name____________________________________________________________
Home/ Phone (____)_______________ Work/ Cell Phone ( ___
)___________________
Family member’s service info: Service
Branch
□ Air Force
□ Army
Component
□ Active
Duty
□ National
Guard
□ Reserves
Deployment Status
□ Currently deployed
□ Recently returned
□ Deployment
pending
CAMP FEE: $50.00(Lunch is included)
Please make checks payable to Peach State STARBASE Foundation.
Call Sign ______________ _________________
No more than two words, must be positive!
EMERGENCY INFORMATION
Emergency Contact___________________________ Ph
#(______)___________
Please note any medical problems (allergies, illnesses, etc.) or special
educational issues, which a chaperone shouldknow
________________________________
In case of an emergency, I authorize STARBASE and/or accompanying
chaperone to obtain medical aid for my child or ward, if they deem
necessary. I agree the cost of such medical care is my responsibility or that
of my child’s health insurer.

3. July 22-25, 2013
STUDENT RELEASE OF LIABILITY FORM
I hereby grant permission for the aforementioned minor to participate in
the Peach State STARBASE program.Iunderstand that participation is
voluntary. I also acknowledge that photographs and video may be used to
document and promote Peach State STARBASE activities and hereby
consent to the use of photographs of the aforementioned minor for these
purposes. I further agree not to hold the United States Government, the
state of Georgia, Dobbins Air Reserve Base, its officers, employees, and
agent, Peach State STARBASE, Atlanta Public Schools, Cobb County Schools
or Marietta City Schools, or volunteers supporting the program liable for any
reason as a result of participation in the program.
__________________________________ ____________________
Parent or Guardian Signature* Date
*Signature is required. Unsigned applications will not be accepted.
Please enclose $50.00 registration fee, payable to Peach State STARBASE
Foundation. Completed applications should be mailed to:
Kara B. Coleman
Child & Youth Services Director
GA National Guard State Youth Program
CNGC 1000 Halsey Ave., BLDG 447
840 Finch Center
Marietta, GA 30060
If you have any questions about this program, please contact:
kara.b.coleman2.nfg@mail.mil or mark.d.richards17.nfg@mail.mil

4. July 22-25, 2013
Code of Conduct
To ensure that the „The STARBASE Camp‟ is a positive and enjoyable experience for all
participants, it is necessary to establish and enforce high standards of behavior. Please
read the following and sign below.
I, a STARBASE Camp participant, will uphold the following conduct and behavior
standards:
I will be courteous and respectful towards others.
I agree to value and respect others‟ ideas, regardless whether they are the same
as my own.
I will actively participate in all missions during workshop sessions.
I will conduct myself in a professional manner at all times.
I will dress appropriately at all times. Revealing clothing or apparel featuring
alcohol, tobacco, and other drug messages are prohibited.
I will not use any alcohol, tobacco, or other drugs, or engage in any behavior of a
sexual or violent nature at any time during the camp.
As a STARBASE Camp participant, I pledge to uphold this commitment. I understand
that if I am not able to remain in good standing or violate the Code of Conduct during this
event, I will be asked to leave.
____________________________ _________________
Youth Signature Date
I have witnessed the pledge made my son/daughter and understand that if my
son/daughter breaks any of the commitments stated in this Code of Conduct, they will be
dismissed from this event.
____________________________ _________________
Parent/Guardian Signature Date
____________________________ _________________
Child & Youth Director Signature Date

5. July 22-25, 2013
MEDICAL RELEASE:
Complete the information below. If your child has allergies, medication needs or any other medical condition
we need to be aware of, please let us know.
YES NO Medical condition or needs that require monitoring: ________________________
____________________________________________________________________________
YES NO Allergies (Food, medicine, insects, etc.): _________________________________
_____________________________________________________________________________
YES NO Currently taking medication (including prescription or over-the-counter medication):
_____________________________________________________________________________
YES NO My child has permission to administer his/her own medication. If “NO”, the
following individual will dispense all medication to my child: _______________
In order to dispense medication we need to know the following:
□ Condition for which it is given: ____________________________________________
□ Exact name of medication(s): _____________________________________________
□ Dosage: _____________________________________________________________
□ When it should be given: ________________________________________________
NOTE: All medication must be in its original container to include any items (inhalers, spoons, cups,
etc.) which will be needed to properly dispense the medication.
_____________________________ ________________________
Parent or Legal Guardian Signature Date
MEDICAL ADMINISTRATION RECORD:
DATE MEDICATION DOSAGE TIME ADMINISTERED BY
AUTHORIZATION TO TREAT:
I hereby give permission to medical personnel selected by Peach State STARBASE to provide for
emergency medical treatment and necessary transportation for my child. In the event I cannot be reached in
an emergency, I hereby give permission to the physician and other appropriate medical personnel to secure
and administer treatment including hospitalization.
Emergency Contact with phone number _____________________________________________
_______________________________________ _____________________________
Parent or Legal Guardian Date