STEAM ASTRO CAMP - Event registration

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Event Timing: Summer and yearlong 2022
Event Address: Natchitoches Parish Library and ET Department at NSU
Contact us at steminfos@gmail.com or engineering@nsula.edu

Email *

Student Name: *

Home address including State/Country *

Parent/Guardian name: *

Parent’s/Guardian’s email address: *

Gender: *

Male

Female

Other:

Ethnicity: *

White

African American

Native American

Hispanic

Asian Pacific Island

Other:

Grade level *

Other:

What event will you attend? *

Summer STEM camp (June 6 -10)

Yearlong STEAM activities (after school program starting April 2022)

NASA day (TBD)

Required

T-Shirt Size

Youth-XS

Youth-S

Youth-M

Youth-L

Adult-S

Adult-M

Adult-L

Adult-XL

Adult-2XL

Adult-3XL

Other:

Clear selection

Dietary restrictions *

None

Vegetarian

Vegan

Kosher

Gluten-free

Halal

Other:

Media Release

I am the parent/guardian/legal representative of the student above and do hereby give permission for the above-named minor child (hereinafter "Minor") to be photographed and/or videotaped by NASA, STEM Pioneers, NSU or their representatives. I understand and agree that the photographs and/or videotapes containing the image and/or voice of the Minor may be used in the production of instructional and/or promotional materials produced by or on behalf of NASA, STEM Pioneers, or NSU (hereinafter the "Program") and that such materials may be distributed or broadcast to the public and displayed publicly. I also understand that my permission to use the photographs and videotapes is for an unlimited duration and that neither I nor the Minor will receive any compensation for granting this permission or for the use, if any, by NASA, STEM Pioneers, or NSU of the Minor's image and/or voice.

I acknowledge that NASA, STEM Pioneers, or NSU has no obligation to use the Minor's image or voice in connection with the Program.

I hereby unconditionally release NASA, STEM Pioneers, or NSU and their representatives from any and all claims and demands arising out of the activities authorized under the terms of this agreement.

By providing my name here, I confirm that I am at least 18 years of age and am the parent/guardian/legal representative of the above-named Minor. I have read the foregoing agreement and am familiar with all of the terms and conditions thereof and I consent to its execution by the Minor. I agree that neither I nor the Minor will revoke or disaffirm this agreement at any time.

Organizations
NASA: National Aeronautics and Space Administration
NSU: Northwestern State University of Louisiana
STEM Pioneers

I have read the media release information and I agree with all its contents *

Yes

I have read the media release information above and I agree with all its contents: (Print your name) *

Emergency contact and relation: *

Emergency phone number : *

Would you like to be added to our contact list? *

Yes

Please list any other information you’d like to include about your camper (None if not applicable) *

I understand that the camp is FREE and my child will follow all the instructions, and complete all the activities, otherwise, they may be dismissed *

Yes

Required

I understand that the program DOES NOT provide any sort of transportation to (or from) any of our events including field trips (if any). Parents are responsible for their children’s transportation. *

Yes

Required

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