2016 Explore Engineering
Program/Field Study Permission & Student Checkout
Program Participation and Field Study-travel Permission:
I agree to allow my child to participate in the Explore Engineering Program, June 20 – June 24, 2016, and attend any
educational study trips scheduled throughout the camp. I understand that program rules and regulations apply at all
times, including study trips and that transportation will be provided for all study trips by Explore Engineering.
Student Personal Information:
Student Name: Birth date:
Schoo
l Attending: ______________________________ Current Grade: _________
Parent/Guardian Name:
Address:
Street City Zip
Home Telephone: Message Telephone: E-mail Address:_____________
If applying for a scholarship, please indicate whether you are eligible for free or reduced lunch at your school.
Check One: Yes No
Person
other than parent/guardian to contact in case of an emergency:
Name: Relationship:
Phone: __________________________ Phone #2: _________________________
Family Doctor: Doctor’s Telephone:
Allergic to medication: Current Medication(s):
Student Pick-Up Authorization
In any event that my child should need to leave CSUF during camp program hours, and I cannot be contacted, the
individual/s listed below have my authorization to pick him/her up in my place.
Please note: If your son or daughter is checking out with someone other than a parent/guardian a valid
identification will be required.
AGR
EEMENT: I understand that pictures may be taken of program events and activities for the purposes of publicity
and public relations. I further give my permission of any likeness of me or my child captured on these pictures to be
used, as the program deems necessary.
AGR
EEMENT: By signing this Electronic Signature Acknowledgment Form, I agree that my electronic signature is the
legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same
validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my
electronic signature or claim that my electronic signature is not legally binding. By signing below, I accept the
conditions of this agreement.
Parent/Guardian Signature Date:
2
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signature
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