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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. ____________________________
_____________________ Date
_____________________ Date
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
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.
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.
Dosage
Times Taken
Please include any additional remarks and special instructions to better assist emergency service personnel. Please explain yes answers on this page.