Parental / Guardian Information and Authorization TechXploration Summer Camp

Name of the student:

First:
Last:

Provide Parental Information

Father's Name:

Occupation:

Work Phone:

Mother's Name:

Occupation:

Work Phone:

Other Legal Guardian:

Occupation:

Work Phone:

Who is the primary student contact from the list above?
Father Mother Legal Guardian

Can this student participate in normal activities? If no, explain.

Does this student have medical or physical conditions, any dietary, medical or behavioral concerns we should be aware of? If yes, explain.

All of the below events (except for Liberty Science Center) take place at:
Middlesex County College, Technical Services Center
2600 Woodbridge Ave., Edison, NJ 08818, 732-906-4178

I understand that there are parent/student activities critical to the camp experience and I agree to attend the following:

  1. Student pre-camp interview - date TBD
  2. Pre-camp orientation - date TBD
  3. Exhibit at Liberty Science Center - date TBD
  4. Fall event - date TBD
  5. Spring event - date TBD

TRAVEL PLANS: What transportation will the student be utilizing to get to and from the camp? Check those that apply:

Parent/ Guardian pick-up (please provide the names of those individuals authorized):

  1. Name of individual:    
    Relationship to child:
  2. Name of individual:    
    Relationship to child:
  3. Name of individual:    
    Relationship to child:

Mass Transit. Please specify bus/train numbers, times, etc:

Other. Please describe/explain:

By checking the box below, I permit participation in a full range of activities and authorize the NJCATE staff in the event of accident or illness, to authorize on my behalf all procedures, including admission to hospital and necessary treatment therein, as he/she may deem essential for the care and well-being of the participant. Such action is to be taken only when immediate contact the undersigned cannot be made. I understand that pictures/slides/videos taken at camp may be used for promotion, unless advised otherwise in writing.

I agree I do not agree

For more information or if you have any questions, please contact:
Josephine Lamela
Middlesex County College
2600 Woodbridge Avenue
Edison, NJ 08818
jlamela@middlesexcc.edu
Ph. 732.548.6000 x3007