STEAM Team Summer Academy

University of San Diego, August 7-12 + Aug. 13 conference, 2016: 9:00 a.m. to 4:00 p.m.

EMERGENCY AND HEALTH INFORMATION

Name _____________________________________ email______________________________

School and grade in fall 2016 _____________________________________________________

School Grade

Home Address _________________________________________________________________

Street Address City State Zip code

Parent/Guardian 1:

Name ____________________________________ email address___________________________

Home Address _________________________________________________________________

Street Address City State Zip code

Telephone numbers:

Home_____________________ Work_____________________ Mobile_____________________

Parent/Guardian 2:

Name ____________________________________ email address___________________________

Home Address _________________________________________________________________

Street Address City State Zip code

Telephone numbers:

Home_____________________ Work_____________________ Mobile_____________________

EMERGENCY INFORMATION:

Provide the information of two people to be contacted in case of an emergency if the parents/guardians are not available. Your child will not be released to anyone except those listed on this form.

Emergency Contact 1:

Name ____________________________________ email address___________________________

Telephone numbers: Home________________ Work________________Mobile________________

Emergency Contact 2:

Name ____________________________________ email address___________________________

Telephone numbers: Home________________ Work________________Mobile________________

HEALTH INFORMATION

Child’s Doctor:_______________________ Telephone Number______________________________

Child’s Dentist:_______________________ Telephone Number______________________________

Medical Insurance Carrier: (HMO – MediCal – Private – None)_______________________________

Does your child have a Life Threatening Allergy? _____YES _____NO

If yes, to what? Food (type)________________________Other (type) _________________________

Please describe:

Please describe information of anything else that may affect your child at the workshop:

I HAVE REVIEWED AND UPDATED THE ABOVE EMERGENCY AND HEALTH INFORMATION.

_________________________________ ____________________________ ______________

Parent / Guardian Signature Print Name Date

RELEASE FORM FOR MEDIA RECORDING

I, the undersigned, do hereby consent and agree that the University of San Diego, its employees, or agents have the right to take my daughter’s/son’s photographs, videotape, or digital recordings to use any and all media, now or hereafter, including composite or partial representations, for recruitment, advertising, instruction, or any other lawful purpose; and I waive any right to inspect or approve the finished product, including written copy that may be created in connection therewith. However, no names will be used to identify persons in media without expressed permission. I understand that there will be no financial or other remuneration for photographing or videotaping my son or daughter.

I also understand that the University of San Diego is not responsible for any expense or liability incurred as a result of my son’s/daughter’s participation in this recording, including medical expenses due to any sickness or injury incurred as a result.

_________________________________ ____________________________ ______________

Parent / Guardian Signature Print Student Name Date

_________________________________ ____________________________ ______________

Student Signature Print Student Name Date