SCIENCE DAY CAMP REGISTRATION FORM

Mon thru Fri, June 17-21, 2013, 9:00am-5:00pm Cal Poly Campus, San Luis Obispo
Cal Poly and the IEEE San Luis Obispo Student Branch are sponsoring a 5-day science camp on the Cal Poly campus. Topics will include robotics, alternative energy sources, laser target assembly and amateur radio activities. There will also be a variety of fun activities, such as friendly competitions, outside games, bowling and an ice cream social. The event is limited to 35 registrants, grades 6-10 (as of school year 2013-2014). The cost is $175. Lunch is not provided. Attendees may bring their lunch or purchase it on campus. Registrants will meet in the lobby of Building 20A, however, camp activities will take place in a variety of areas on campus. If you have questions, please contact Lani Woods, Dennis Derickson or the EE department office. EE Department office, Building 20A, 805-756-2781 Lani Woods, Electrical Engineering Administrator, Cal Poly 805-756-6320 or llwoods@calpoly.edu Dennis Derickson, Electrical Engineering Chair, Cal Poly at (805) 756-7584 or ddericks@calpoly.edu. --------------------------------------Please return the completed and signed registration, medical release and medical history forms, along with a check in the amount of $175 made payable to Cal Poly Electrical Engineering Department to: Lani Woods, Electrical Engineering Department, 1 Grand Avenue, California Polytechnic State University, San Luis Obispo, CA 93407. Registration will be confirmed to the email address listed below. You will also be provided a campus map and event schedule prior to the event.

Name of Registrant ___________________________________________ Grade (as of fall 2013) ____________ Address __________________________________________________ Ph No. ___________________________ Email ________________________________________ Cell or Alternate No. ____________________________

_______________________________________________ Signature of Registrant

_____________________ Date

_______________________________________________ Signature of Parent/Legal Guardian

_____________________ Date

California Polytechnic State University Medical Release Form

This Medical Release Form is authorized for the Cal Poly and IEEE sponsored Science Day Camp to be held on the Cal Poly Campus Monday-Friday from 9:00a-5:00p, June 17-21, 2013. __________________________________________________________________________ Last Name First Name __________________ Age

__________________________________________________________________________________________________ Address (Street, City, State, Zip Code)

While my child participates in Science Day Camp, I HEREBY AUTHORIZE any adult accompanying or assisting him/her, TO CONSENT TO THE FOLLOWING MEDICAL TREATMENT FOR SAID MINOR: Any x-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care which is deemed advisable by, and is to be rendered under the general or special supervision of any physician and/or surgeon licensed under the provisions of the Medical Practices Act, California Business and Professions Code Section 2000 et seq.; or any x-ray examination, anesthetic, dental or surgical diagnosis or treatment, and hospital care to be rendered by a dentist licensed under the provisions of the Dental Practices Act, California Business and Professions Code Section 1600 et seq. This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California. This authorization shall remain effective until my child completes Science Day Camp unless sooner revoked in writing. I understand that as a parent/guardian, I will be responsible for the cost of any service or treatment provided.

EMERGENCY CONTACT INFORMATION

_____________________________________________________________________________________________ Name Relationship to Youth Identified Above (______)__________________________________________ Emergency Day Phone (with area code) (______)__________________________________ Emergency Night Phone (with area code)

_____________________________________________________________________________________________ Mailing Address City State Zip

I hereby certify that my child is in good health and can travel to and participate in the Science Day Camp. I understand is it my responsibility to keep the information on this form updated (including Health History and parent/guardian status). _________________________________________________ Signature of Parent/Guardian _____________ Date

AUTHORIZATION AND CONSENT AND RELEASE

I do not desire to sign this authorization and understand that this will prohibit my child from receiving any non-life threatening medical attention in the event of illness or accident. _________________________________________________ Signature of Parent/Guardian _____________ Date

NON-CONSENT

The information entered on this form is collected under authority of the Smith-Lever Act. Submission of the medical data is voluntary. However, a signature is required on one or the other of the two signature lines above. Failure to provide the medical information and authorization may result in our inability to provide necessary medical treatment. Any known or foreseeable intergovernmental transfer that may be made of the information is as follows: None.

Health History Information

_________________________________________________ First Name Last Name Subject to: Colds Sore Throat Fainting Spells Bronchitis Convulsions Cramps Allergies Wear corrective lenses? Is hearing good? YES No ________________________ County ______/_______/______ Date of Birth Yes No

Now Have or Have Had Heart Trouble Asthma Lung Trouble Sinus Trouble Hernia (rupture) Appendicitis Has appendix been removed? Do you walk in your sleep?

Date of last Tetanus Vaccination: ____________________________ Please check over-the-counter medications that may be administered: Tylenol Ibuprofen Cough Syrup Antacid Polysporin Hydrocortisone Decongestant Dramamine Other: ________________________________________

Please identify allergies including allergies to food, medications, and drug reactions:

Please list any disability accommodations you will need in order to participate in this program or activity.

Please list all current medications: Name of Medication

Dosage

Times Taken

Please include any additional remarks and special instructions to better assist emergency service personnel. Please explain yes answers on this page.