Steuben Space Academy Summer Camp 2024

An academic summer camp for students in grades 1-8, funded by the Literacy Coalition's 21st Century Community Learning Center grant, and in partnership with Angola Parks and Recreation.  The program will operate for 3 weeks in the summer of 2024.  The program will be held from 8-Noon, Monday-Friday.  Students will have the opportunity to engage in hands-on science, technology, engineering and math activities.  These activities may include rocketry, robotics, life on Mars, what makes the weather change and more!  Don't miss this opportunity.  Each week will feature new activities, so elementary students can participate in both weeks, if spots are available.  Applications will be accepted on a first come, first serve basis.   Only 30 students can be accepted each week.  
Sign in to Google to save your progress. Learn more
Email *
Week Attending Program *
Student Name *
Date of Birth *
MM
/
DD
/
YYYY
Grade Entering Fall 2024 *
School Attending *
Gender *
Home Address *
Township *
Parent/Guardian Name *
Parent/Guardian Phone *
Emergency Contact Name During Camp Hours if Parent/Guardian Cannot Be Reached *
Emergency Contact Phone Number *
Names and Phone Numbers of Additional Adults Authorized to Pick Up the Student *
Please list any medical conditions or allergies the student has (including food allergies) *
By clicking "I agree" below, I (the parent/guardian of the student on this application) hereby consent to photographs, videos, biographical information of my child, and/or writings and/or audio recordings made of my child's voice to be used by the Steuben County Literacy Coalition (SCLC), in whatever way they deem necessary for communication, media relations, advertising, which may include, but is not limited to, print, media, television, SCLC collaterals, SCLC advertising, social media  and the SCLC website; futhermore I hereby consent that such photographs, films, recordings or writings and the plates, tapes or disks, or digital media from which they were made shall become property of SCLC.  SCLC shall have the right to sell, duplicate, reproduce and make other uses of such photographs, films, writing, plates, tapes and disks and digital media as they deem necessary, free and clear of any claim whatsoever on my part. *
Emergency Medical Waiver:  I do hereby state that I am the parent/guardian of the minor on this form, who resides with me at the address provided.  I authorize anyone who is authorized to represent SCLC at Steuben Space Academy, to consent to any necessary examination, anesthetic, medical diagnosis, surgery or treatment and/or hospital care to be rendered to the above-named minor under the general or special supervision and on the advice of any physician or surgeon licensed to practice medicine in the continental USA.  It is understood that this is for emergency medical treatment in the event that I am unable to be contacted. *
Child's Doctor and Phone # *
Preferred Hospital *
The Steuben Space Academy and SCLC administration will make a conscious effort to ensure that all students and staff are safe from harm, injury and illness (including COVID19) while participating in camp.  However, SCLC and the Angola Parks Dept will not be held liable for injury, accident or illness occurring during the program. By typing my name below, I am certifying that I have read the above statements and fully understand.   *
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms