EMH Summer Camp Application: June 1-2 Setup and Take Your Own 3D Printer

$500 Upcoming Grades: 5th-7th Learn about 3D modeling and printing. Set-up your own 3D printer and take it home! Bring your own laptop preferred. Please fill out the following information. You will be contacted via email for payment options.

Name of Camper *
Preferred Pronoun
Birthday Birthday * / MM / DD YYYY
Current School *
Grade in Fall 2019 *

Grade in Fall 2019 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th
Name of Parent(s) or Guardian(s) *
Relationship to Camper *
Phone of Parent(s) or Guardian(s) Phone of Parent(s) or Guardian(s) * - ### - ### ####
Email (Please fill in if you wish to receive a confirmation email) *
Additional Name of Parent(s) or Guardian(s)
Relationship to Camper
Additional Phone of Parent(s) or Guardian(s) Additional Phone of Parent(s) or Guardian(s) - ### - ### ####
Email
Emergency Contact Name and Relationship to Camper *
Emergency Contact Phone Emergency Contact Phone * - ### - ### ####
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

Due to unpredictability of COVID regulations and safety measures, there is the possibility that face-to-face camps will need to move online with safe contact measures for delivery of physically created objects. What is your preference for camp delivery method? *
	Face-to-Face	Online	Hybrid	Does not matter
Preferred Camp Delivery Method	Preferred Camp Delivery MethodFace-to-Face	Preferred Camp Delivery MethodOnline	Preferred Camp Delivery MethodHybrid	Preferred Camp Delivery MethodDoes not matter

Please explain your preference. We will try to accommodate the best we can.

For your child to receive medical care in the event of illness or injury while participating in the USM event, we ask that you bring a copy of all relevant insurance information for your child with you to the event. We will store it securely until the end of the program, where we will then return the copy to you. *
	Yes	No
Is it permissible to provide medical treatment for your child if needed?	Is it permissible to provide medical treatment for your child if needed?Yes	Is it permissible to provide medical treatment for your child if needed?No

Please state any special medical conditions that may require staff attention:

*
	Yes	No
Does your child take medication on a regular basis of which we need to be aware?	Does your child take medication on a regular basis of which we need to be aware?Yes	Does your child take medication on a regular basis of which we need to be aware?No

If yes, please explain:

*
	Yes	No
Does your child have any known allergies?	Does your child have any known allergies?Yes	Does your child have any known allergies?No

If yes, please explain:

*
	Yes	No
Is your child under the care of a psychologist/psychiatrist, or being treated for any emotional or mental issues?	Is your child under the care of a psychologist/psychiatrist, or being treated for any emotional or mental issues?Yes	Is your child under the care of a psychologist/psychiatrist, or being treated for any emotional or mental issues?No

If yes, please explain:

*
	Yes	No
Are there any restrictions of physical activity that may apply to your child?	Are there any restrictions of physical activity that may apply to your child?Yes	Are there any restrictions of physical activity that may apply to your child?No

If yes, please explain:
Photography and Additional Event Information

Photography and Additional Event Information Yes, I grant permission for my child to be photographed or videotaped during this event. This includes photos that may be used for promotional or publicity purposes. Yes, I would like to receive information about other events through Eagle Maker Hub at USM
I certify that my child has permission to attend Summer Camp event at USM’s Eagle Maker Hub.
I release USM from any and every liability, claim, right of action of any kind or nature which my child or legal representative may have for any and all bodily or personal injuries or property damages or any other damages resulting there from which might occur during participation in this program and host institution(s), or representative(s) thereof, and the management or owner(s) of any physical facility in which the program is conducted.

1. When you submit the form you will receive an email confirmation with a PDF containing all the information you entered. Please print the PDF and sign and date below in ink.

2. Include check or school PO for the event(s) checked above.

3. Mail signed PDF and payment to:
Attn: Anna Wan - Eagle Maker Hub
Univ. of Southern Mississippi
118 College Drive #5043
Hattiesburg, MS 39406-0001

Clear
For questions, please email anna.wan@usm.edu or call (601) 266-4303. If you have any additional questions, you can also fill it out below.