2019 Student Enrollment General Engineering Middle School

I would like my child to attend the following program:*

General Engineering - Middle School (June 17 - 21)
General Engineering - Middle School (June 24 - 28)

Grades 6 - 8. Place camper based on 2019-2020 school year.

Participant's Name*

First Last

Participant's Preferred Name*

This name will appear on the participant's name tag.

Participant's Birthdate (mm/yyyy)*

Participant's CURRENT grade*

5th Grade
6th Grade
7th Grade

Participant's CURRENT school*

Gender

Female
Male

Ethnicity*

African American
Asian
Caucasian
Hispanic
Native American
Other
Prefer not to disclose

Parent or Guardian 1*

First Last

Parent or Guardian 1 Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Parent or Guardian 1 Daytime Phone*

Parent or Guardian 1 Cell Phone*

Parent or Guardian 1 Email*

Enter Email Confirm Email

Parent or Guardian 2

First Last

Parent or Guardian 2 Address (if different than above)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Parent or Guardian 2 Daytime Phone

Parent or Guardian 2 Cell Phone

Parent or Guardian 2 Email

Enter Email Confirm Email

OPTIONAL question for past attendees: Tell us how you applied the knowledge and experience you gained while attending ECC.

How did you hear about our program?*

Participant's t-shirt size*

Youth t-shirt sizes run small.

Please provide us with any food allergies or additional medical information you would like to share regarding your child. This information will be communicated directly with your child's team lead and assistant team lead. If applicable allergies or medications change, please contact Jennifer at jennifer@cynosurelearning.com to update.

We are unable to honor group requests. This section is designated for medical information only. Thank you.

Please choose one of the following*

In the event of any medical emergency, I authorize and consent to any x-ray examination, anesthetic, medical, dental or surgical diagnosis or treatment, and hospital care that Queens University of Charlotte personnel deem necessary for my/my minor child’s safety and protection.
In the event of any medical emergency, I DO NOT authorize and consent to any x-ray examination, anesthetic, medical, dental or surgical diagnosis or treatment, and hospital care that Queens University of Charlotte personnel deem necessary for my/my minor child’s safety and protection.

In case of emergency, primary contact is*

First Last

Primary contact phone*

In case of emergency, secondary contact is*

First Last

Secondary contact phone*

During the week photographs and videos may be taken of your child by staff affiliated with the NCSU's Engineering Camp Charlotte. This media may be used for promotional purposes and in other university publications. At times, members of the news media or others associated with documenting our summer programs may also be present to take pictures or video.*

I give my permission for my child to be photographed or videoed while participating in NCSU's Engineering Camp Charlotte.
I DO NOT give my permission for my child to be photographed or videoed while participating in NCSU's Engineering Camp Charlotte.

Program Fees*

Tuition
Optional Lunch

Pricing is per camper

Total

$0.00

Credit Card*

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Product Name

2019 Student Enrollment Form - General Engineering Middle School