2016 Summer Engineering Experience
Program/Field Study Permission & Student Checkout
Program Participation and Field Study-travel Permission:
I agree to allow my child to participate in the Summer Engineering Experience (SEE), June 27
th
– July 1
st
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 SEE.
Student Personal Information:
Student Name: ______ Birth date:
School
Attending: ______________________________ Current Grade (Fall 2016): _________
Last Mat
h Completed:
Parent/Guardian Name:
Address:
Street City Zip
Home Telephone: Message Phone: E-mail Address:_____________
If applying for a scholarship, please indicate whether you are eligible for free or reduced lunch at your school.
Please provide proof. Check One: Yes No
Other
person 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.
AGREEM
ENT: 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.
AGREEM
ENT: 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
click to sign
signature
click to edit
![]()
