Fayette County WV Science Adventures & NYSF Summer Camp Registration Form

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@ Summit Bechtel Reserve

Email *

Child's Full Name *

Child's Academic Placement (as of Fall 2022) *

Grade 4-5

Grade 6-8

Grade 9-10

Child's Gender *

Girl

Boy

Other:

COVID-19 Vaccine Status (Vaccine cards will need to be shown on the first day of camp at drop off) *

Two doses of BioNTech/Pfizer + Booster (12 and older)

Two doses of BioNTech/Pfizer (11 and under, no booster recommended)

My child will be vaccinated by the time camp begins

I need help getting my child vaccinated (We will follow up)

Parent/Guardian Name *

Parent/Guardian home/cell number *

Parent/Guardian e-mail address *

Home Address *

Emergency Contact Name (and relationship to the child) *

Emergency Contact Phone Number *

Special Considerations, Food Allergies, or Other Medical Considerations (Lunch is provided and food allergies will be accommodated. Some time at camps may be spent outdoors doing more physically strenuous activities). *

Which Fayette County camp(s) are you registering for? *

Paws, Scales, and Tails, grades 4-9 (June 27-July 1)

Wonders of Water, grades 4-9 (July 11-15)

Molecular Biology: LIfe at the Cellular Level, grades 5-10 (July 18-22)

LEGOs, Robotics, 3D Printing, and Drones, grades 5-10 (July 25-29)

Required

If you selected multiple camps, please rank camps in order of preference (camps are filled first come first served with even numbers of boys and girls if possible)

Paws, Scales, and Tails

Wonders of Water

Molecular Biology

LEGOs, Robotics, 3D Printing, and Drones

1st Choice

2nd Choice

3rd Choice

4th Choice

Clear selection

Is your family eligible for a scholarship(s)? (In other words, does your child qualify for free lunch at school?) *

Yes

Not sure (We will follow up for more information)

Media Release: do you, as the legal guardian of the child being registered, grant permission for WV Science Adventures and NYSF to reproduce photographs taken of yourself and members of your family for the purpose of publication, promotion, illustration, advertising, or trade, in any manner or any medium? *

Yes, I grant permission.

No, I do not grant permission.

Liability Release: I understand that participation in the above event or activity could include actions or tasks which might be hazardous to the participant named above. By acknowledging below, I assume any risk of harm or injury which might occur to the participant due to his/her/my participation in the event or activity. I release the organization or business named above from all liability, costs and damages which might arise from participation in the above named event or activity. If the participant is a minor, I agree that the minor has my consent to participate in the event or activity. I further provide my consent for the organization or business named above to seek emergency treatment for the minor if necessary. I agree to accept financial responsibility for the costs related to this emergency treatment. *

I acknowledge having read and consent to the liability release.

A copy of your responses will be emailed to the address you provided.

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