Science, Technology, Engineering, and M Athematics

STEM Summer Camp

(Science, Technology, Engineering, and Mathematics)

July6-10, 2015

Registration Form

Directions:Return this completed registration form, Summer School Student Health Information (attached), Media Release form (attached), and camp fee of $50.00 (if applicable) by April 30, 2015 to your principal. Checks only (no cash); made payable to: “Loudoun County Public Schools”.

Name of student ______Nickname ______

Student Number*(Lunch #) ______(Required) Male____ Female ____

School: ______Current Grade Grade Next Year ______

Home Address:

City, State, Zip:

Best phone number(s) to reach parents in case of an emergency

______

List the full name(s) of all persons authorized to pick up your students from the STEM camp:

Describe and medical condition/s or special needs of the above student:

Did your child attend STEM CAMP last year? ______Yes ______No

Has your child ever attended STEM camp? ______Yes ______No

Will your child be taking the bus to camp? ______Yes ______No

Parent/Guardian Name

Parent/Guardian Signature

Please indicate by checking box if financial assistance is requested.

Media Release

Photographs/Videos of Students in School Activities

Students may occasionally be photographed or videotaped during their participation in school activities.These photographs may be used for information purposes within the school system and they may also beused to provide information to the public about Loudoun County Public Schools (LCPS) programs and activitiesthrough school system publications and displays, in newspapers and other print media, on television,and in connection with school system information provided on the Internet.

PLEASE CHECK THE APPROPRIATE BOX BELOW AND RETURN THE SIGNED AND COMPLETED FORM WITH YOUR STEM CAMP APPLICATION.

_____ I do not grant permission for my child (named below) to be photographed or featured in any videotape, television, audio recording, or broadcast that will be produced by and available

to the public from LCPS, or (to the extent that access is within LCPS’ control duringschool hours) the media.

_____ I grant permission for my child (named below) to be photographed or featured in any

videotape, television, audio recording, or broadcast that will be produced by and available

to the public from LCPS, or (to the extent that access is within LCPS’ control duringschool hours) the media.

______

Student’s Name

______

School

______

Parent/Guardian’s Signature

______

Date

EMERGENCY INFORMATION

The following is requested in order that we may have the necessary information in the event of illness or injury involving your child when we are unable to reach you.

Student’s full name ______

Home School ______Grade ______

Stem Camp Attending STERLING MIDDLE SCHOOL

Contact Information

Parent/Guardian 1Parent/Guardian 2

Name ______Name ______

Home Phone ______Home Phone ______

Cell Phone ______Cell Phone ______

Work Phone ______Work Phone ______

Emergency Information

The following is requested in order that we have the necessary information in case of illness or injury to your child when we are unable to reach you.

Medical Insurance: Yes: ___ No: ___

Doctor’s Name:______Phone:______

Emergency Contact 1Emergency Contact 2

Name of person to whom your child may be releasedName of person to whom your child may be release

Name ______Name ______

Home Phone ______Home Phone ______

Cell Phone ______Cell Phone ______

Work Phone ______Work Phone ______

MEDICAL INFORMATION

Tylenol/Generic Substitute: (check one)

____ I DO give permission for my child to receive Tylenol or its generic substitute. (Age/weight appropriate dose will be given)

____ I do NOT give permission for my child to receive Tylenol or its generic substitute.

PLEASE LIST:

1. Medication taken regularly by student ______

2. Medication to be given during Summer School: ______

Prescription medicines require physician’s orders. If medication was administered during the school year, a new order is not required. If this is a new medication, a physician’s order is required. Forms for medication are available in the school office.

3. Allergies (list all): ______

4. Does your child have any of the following medical conditions? (check all that apply)

If yes, please request special medical forms from the school office.

If forms are on file for current school year, then new forms are not required for summer school.

____ Asthma ____ Seizures

____ Severe Allergies requiring an EpiPen ____ Diastat

____ Diabetes ____ Tube Feeding

____ Cardiac Condition ____ Other

5. Any physical or medical problems about which the school should know? Yes: ____ No: ____

If yes, list conditions: ______

If yes, write comments relating to care ______

______

In case of an accident or serious illness, I request the school to contact me. In case of an emergency, I hereby authorize the school to contact a physician, and further authorize the school to transport my child to the physician or hospital. It is understood that I will assume the responsibility for payment of the physician’s and/or hospital’s fee. It is further understood that this permission is effective as long as this child is enrolled in school.

X ______X ______

Signature of Parent/Guardian Date Signature of Parent/Guardian Date