Gravitational Wave Summer Camp Registration

July 19 - 21, 2016

Penn State's University Park Campus

***Due to an overwhelming response, our camp enrollment has exceeded capacity
and all remaining applications will be placed on a waiting list.***

Participant Information:     (* = Required Field
First Name:*
Last Name:*
Gender: Female     Male     Other
Zip Code:*
Grade (in Fall 2016):*
High School:* Bellefonte
Bald Eagle
Centre County Private or Charter School
Home School
Penns Valley
State College
Email Address:*
Cell Phone #:*
T-Shirt Size:*
Interest Statement
(text box will expand):*

Parent/Guardian Information:     (* = Required Field)
Parent/Guardian #1
Full Name:*
Parent/Guardian #1
Phone Number:*
Parent/Guardian #1
Secondary Phone:*
Parent/Guardian #1
Email Address:*
Parent/Guardian #2
Full Name:
Parent/Guardian #2
Phone Number:
Parent/Guardian #2
Mobile/Cell Phone:
Parent/Guardian #2
Email Address:

I am the parent and/or the legal guardian of the above-named student and attest that the student is my legal dependent. By clicking the “I Agree" button below, I acknowledge that I, the parent and/or legal guardian, am providing my legally binding signature.

If you disagree with this statement, please “click” the “Clear Form” button below and discontinue the registration process.

I agree

Emergency Contact (other than parent):(* = Required Field)

Non-Parent Emergency Contact's
Full Name:*
Non-Parent Emergency Contact's
Phone Number:*
Non-Parent Emergency Contacts's
Secondary Phone:*

Medical Information: (* = Required Field)

Penn State program officials will not dispense over-the-counter (OTC) or prescription medications to participants. Participants will be allowed to possess and take OTC and prescription medications on their own if permission is granted in writing by the parent(s)/guardian(s). Both OTC and prescription medications must be in their original containers and listed below:

Special instructions and/or physical conditions that the program director and instructors should be aware of (allergies, medications, diet restrictions, disabilities, learning/behavior challenges, etc.). If this participant has no conditions, please write "NONE."*

Photo and Newspaper Policy: (* = Required Field)

I/we authorize The Pennsylvania State University to photograph, videotape and/or audiotape my/our child(ren) in promotion of Penn State's summer youth programs.
Please select one of the following:*

Yes, I have read and agree to the above release.

No, I have read and do not agree to the above release.

Liability Release: (* = Required Field)

In consideration of such admission, I/we hereby agree to release, discharge and hold harmless The Pennsylvania State University, it's officers, agents and employees of and from all causes, liabilities, damages, claims or demands whatsoever on account of any injury of accident involving the said minor arising out of the minor's attendance at the Gravitational Wave Summer Camp program or in the course of laboratory and extra curricular activities held in connection with the Gravitational Wave Summer Camp.
Please select one of the following:*

Yes, I have read and agree to the above release.

No, I have read and do not agree to the above release.

Program Demographics:

Since our program is sponsored in part by federal funds and corporate foundations, we track program demographics for reporting purposes. Names are never reported with this information. Penn State is committed to equal opportunity and nondiscrimination. Providing this information is VOLUNTARY, and it will be kept confidential.

 American Indian/Alaskan Native
 Black/African American
 Native Hawaiian/Pacific Islander
 Two or more
 Do not wish to disclose

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