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Robocamp 2009
Registration Form

Please Check the Camp you wish to attend in the appropriate column. You may list a 1st and 2nd choice if you like. You will be assigned on a space available basis.

Dates Location Camp Type Attendance Cap Attend?
Advanced Robotics Workshop(Previous Robocamp attendees only) Denton 6/29 - 7/1 20 First Choice Second Choice (Waiting List)
Advanced Robotics Workshop(Previous Robocamp attendees only) Dallas 7/13 - 7/15 20 First Choice Second Choice (Waiting List)


Students Name: Year attended first robocamp :
Phone: Email:
Address:    
City, State Zip:    
Date of Birth: Age:
School grade next academic year: Gender (M/F):
T-Shirt Size (S-2XL):

PARENT INFORMATION
Mother/Guardian:    
Daytime #: Email:
Cell phone:    
Father/Guardian:    
Daytime #: Email:
Cell phone:    

Other person(s) who have my permission to pick up the camper from the college:


I, being the parent/guardian of the above named participant, give permission for participant to attend the camp listed above including any field trips away from the campus. I also give permission for the participant to be included in photos (excluding the use of full name or any contact or identifying information), videotapes, recordings, etc to be used for University related activities or publications, and for local, state and national publications approved by the University and the camp directors.

In lieu of signature pleae type name of parent/guardian or self if over 18 years of age





Robocamp Medical Release Form

*** Registrations will be returned if this form is not attached to each student's registration. One form per participant.***
STUDENTS NAME Phone:
Address: City/State/Zip:
Gender (M/F): DOB:
Age:
School:
       
Mother's Name: Home Phone:
Place of Business: Work Phone:
Pager/Cell phone:    
       
Father's Name: Home Phone:
Place of Business: Work Phone:
Pager/Cell phone:    

FAMILY PHYSICIAN: Phone:
Personal Health/Insurance Carrier: Policy #:

Allergies:
Hay Fever Food Insect Bites Drugs
Other:


Any medical conditions? (Please list or explain)


Is person subject to:
Fainting Headaches Nosebleeds Asthma Seizures
Other:


Special Medications:

Will bring to college: YES NO

The person listed above has my permission to be given Tylenol (Acetaminophen) (check one): YES NO

EMERGENCY CONTACT INFORMATION -Please list two persons if parent/guardian cannot be reached:
Name: Relationship:
Day Phone: Evening Phone:
Cell:    
       
Name: Relationship:
Day Phone: Evening Phone:
Cell:    

I authorize the camp director to consent to medical treatment of above listed person when I cannot be contacted. I understand that every effort will be made to contact me before such action is taken. I assume financial responsibility for any and all emergency care, if such care is needed.

In lieu of signature please type in your initials: