FLL Mini-Camp Registration Form
Dates: June 27-30, 2016
Time: 9:00 pm - 12:00 pm
Location: Page County High School
Sponsored by: Page County High School FRC Pan-Tech Robotics Team
For Grades: Upcoming 4th, 5th and 6th graders
Registration Fee: $60.00 per student
Registration Form and Fee must be returned to PCHS by June 22, 2016
Make checks payable to PCHS Robotics Team
Page County High School 184 Panther Drive Shenandoah VA 22849
Questions: Contact BH Snellings at [email protected] or 742-2578 or
Call about late registrations
Camp limited to 18 participants.
FLL Mini Camp Registration Form
Child’s Name: ___________________________________________ Grade: ______________
School: ________________________________________________ Age: _______________
Parent’s Signature: ____________________________________________________________
Parent’s Address: _____________________________________________________________
Home Phone: ___________________________ Cell Phone: ___________________________
Please return this form and the registration fee to PCHS Robotics Team by June 22, 2016
I, the undersigned, individually as parent(s) and guardian(s) of, (Camper’s Name)___________________________________________
a minor, ask that he/she be admitted to participate in this summer camp sponsored by Page County High School FRC Team 3872 and Page County Public Schools. In consideration of my child’s participation in the summer camp, to the extent permitted by law, I hereby accept all risk to my child’s health and of my child’s injury that may result from such participation and I hereby release Page County Public School, its governing board, officers, employees and representatives from any liability to me, my personal representatives, estate, heirs, next of kin, and assigns for any and all claims and causes of action for loss of or damage to my property and for any and all illness or injury to my child, that may result from or occur during my child’s participation in the summer camp. We also will allow photos form the camp to be published.
We intend to have snacks at the camp. Are there any physical conditions that the Camp supervisor should be aware of (include allergies to both food and medicine, recurring illnesses, disabilities, chronic illnesses, etc.):________________________________________________________________________________
Please list any medications camper is currently taking:_________________________________________________________________
I hereby authorize the PCHS Robotics Camp staff and referred doctors, nurses or emergency medical personnel to provide care that includes routine diagnostic procedures (i.e. x-rays, blood and urine tests) and medical treatment as necessary to my minor son/daughter _____________________________.
I understand that the consent and authorization herein granted do not include major surgical procedures and are valid only during the camp. In the event that an illness or injury would require more extensive evaluation, I understand that every reasonable attempt will be made to contact me.
However, in the event of an emergency, and if I cannot be reached, I give my consent for physicians, PCHS staff, and emergency personnel to perform any necessary emergency treatment.
BOTH SIGNATURES REQUESTED: