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Summer STEM Camp 2015 Release Form

I, the undersigned, as a parent or guardian of _________________________________________, a minor, ask that he/she be admitted to participate in the Summer Youth Program sponsored by The Pennsylvania State University. In consideration of such admission, I do hereby agree to release, discharge, and hold harmless The Pennsylvania State University, its officers, agents, and employees of and from all causes, liabilities, damages, claims, or demands whatsoever on account of any injury or accident involving the said minor arising out of the minor's attendance at the Summer Youth Program or in the course of activities held in connection with the Summer Youth Program.

I authorize Penn State to photograph, videotape, and/or audiotape my child in promotion of the University or the Summer Youth Program. My child and I understand that all University regulations must be followed. In addition, I have reviewed the Program Rules with my child, who agrees to follow these rules. You may also request to have the rules and regulations mailed to you or you may also pick up a copy on the first day of the program.

I have also completed the Medical Treatment Authorization form and will submit that with this permission form to the University.

Agreed to by: _______________________________________________ Parent’s/Legal Guardian’s Signature

Child’s Name _________________________________Child’s Date of Birth __________________

Address _____________________________________________________________________________________

Parent/ Legal Guardian’s Home Phone _____________________ Cell Phone_________________

Emergency Contact __________________________ Phone_____________________

Parent/Legal Guardian’s E-mail Address_____________________________________

Please mark the week camp that your child would like to attend below:

_______           School District____________

_______          T-Shirt size______________

Free for participants. For more information, please contact Outreach & Continuing Education at 724-430-4211

Mail form to: Penn State Fayette, The Eberly Campus, Continuing Education, 2201 University Drive, Lemont Furnace, PA 15456 or e-mail to lar346@psu.edu