The document appears to be a registration form for the HCC Summer STEM Academy. It consists of 8 pages requesting information such as student and parent details, transportation preferences, medical information, photo/video permissions, and liability waivers. Completing and submitting the form is necessary to register for the summer program at the Houston Community College. Contact information is provided for any additional questions.

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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:

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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 ⃝

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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.

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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

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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.

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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.

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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.

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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.