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July 22-25, 2013
July 22-25, 2013STUDENT APPLICATION/PERMISSION FORMPlease print clearly – Due by Friday, June 14, 2013Childs Name_________...
July 22-25, 2013STUDENT RELEASE OF LIABILITY FORMI hereby grant permission for the aforementioned minor to participate int...
July 22-25, 2013Code of ConductTo ensure that the „The STARBASE Camp‟ is a positive and enjoyable experience for allpartic...
July 22-25, 2013MEDICAL RELEASE:Complete the information below. If your child has allergies, medication needs or any other...
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Star Base Camp at Dobbins!

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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


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Star Base Camp at Dobbins!

  1. 1. July 22-25, 2013
  2. 2. July 22-25, 2013STUDENT APPLICATION/PERMISSION FORMPlease print clearly – Due by Friday, June 14, 2013Childs Name___________________________________________ Female___Male ___StreetAddress__________________________________________________________City___________________________________________ State_______Zip__________ParentsName____________________________________________________________Home/ Phone (____)_______________ Work/ Cell Phone ( ___)___________________Family member’s service info: ServiceBranch□ Air Force□ ArmyComponent□ ActiveDuty□ NationalGuard□ ReservesDeployment Status□ Currently deployed□ Recently returned□ DeploymentpendingCAMP 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 INFORMATIONEmergency Contact___________________________ Ph#(______)___________Please note any medical problems (allergies, illnesses, etc.) or specialeducational issues, which a chaperone shouldknow________________________________In case of an emergency, I authorize STARBASE and/or accompanyingchaperone to obtain medical aid for my child or ward, if they deemnecessary. I agree the cost of such medical care is my responsibility or thatof my child’s health insurer.
  3. 3. July 22-25, 2013STUDENT RELEASE OF LIABILITY FORMI hereby grant permission for the aforementioned minor to participate inthe Peach State STARBASE program.Iunderstand that participation isvoluntary. I also acknowledge that photographs and video may be used todocument and promote Peach State STARBASE activities and herebyconsent to the use of photographs of the aforementioned minor for thesepurposes. I further agree not to hold the United States Government, thestate of Georgia, Dobbins Air Reserve Base, its officers, employees, andagent, Peach State STARBASE, Atlanta Public Schools, Cobb County Schoolsor Marietta City Schools, or volunteers supporting the program liable for anyreason 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 STARBASEFoundation. Completed applications should be mailed to:Kara B. ColemanChild & Youth Services DirectorGA National Guard State Youth ProgramCNGC 1000 Halsey Ave., BLDG 447840 Finch CenterMarietta, GA 30060If you have any questions about this program, please contact:kara.b.coleman2.nfg@mail.mil or mark.d.richards17.nfg@mail.mil
  4. 4. July 22-25, 2013Code of ConductTo ensure that the „The STARBASE Camp‟ is a positive and enjoyable experience for allparticipants, it is necessary to establish and enforce high standards of behavior. Pleaseread the following and sign below.I, a STARBASE Camp participant, will uphold the following conduct and behaviorstandards:I will be courteous and respectful towards others.I agree to value and respect others‟ ideas, regardless whether they are the sameas 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 featuringalcohol, tobacco, and other drug messages are prohibited.I will not use any alcohol, tobacco, or other drugs, or engage in any behavior of asexual or violent nature at any time during the camp.As a STARBASE Camp participant, I pledge to uphold this commitment. I understandthat if I am not able to remain in good standing or violate the Code of Conduct during thisevent, I will be asked to leave.____________________________ _________________Youth Signature DateI have witnessed the pledge made my son/daughter and understand that if myson/daughter breaks any of the commitments stated in this Code of Conduct, they will bedismissed from this event.____________________________ _________________Parent/Guardian Signature Date____________________________ _________________Child & Youth Director Signature Date
  5. 5. July 22-25, 2013MEDICAL RELEASE:Complete the information below. If your child has allergies, medication needs or any other medical conditionwe 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”, thefollowing 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 DateMEDICAL ADMINISTRATION RECORD:DATE MEDICATION DOSAGE TIME ADMINISTERED BYAUTHORIZATION TO TREAT:I hereby give permission to medical personnel selected by Peach State STARBASE to provide foremergency medical treatment and necessary transportation for my child. In the event I cannot be reached inan emergency, I hereby give permission to the physician and other appropriate medical personnel to secureand administer treatment including hospitalization.Emergency Contact with phone number ____________________________________________________________________________________ _____________________________Parent or Legal Guardian Date

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