2020 Enrollment Form 3-8 – Engineering Camp Charlotte

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

General Engineering for Middle School (July 6-10)
General Engineering for Elementary School (July 13-17)
Mechanical Engineering: Machines, Motors & More (July 20-24)
Aerospace Engineering: WEEK IS FULL. EMAIL FOR WAITLIST.

Elementary school includes grades 3-5. Middle school includes grades 6-8. Mechanical and Aerospace engineering includes both grades 3-5 and grades 6-8. Grade placement based on 2020-2021 school year.

Participant's Name*

First Last

Participant's Preferred Name*

Please type exactly how participant's name should be printed on their name tag

Participant's Birthdate*

Participants grade NEXT year (2020-2021 school year)*

Participant's anticipated school NEXT year (2020-2021 school year)*

Ethnicity*

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

Parent or Guardian 1*

First Last

Parent or Guardian 1 Address*

Street Address Address Line 2 City State ZIP 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 Name

First Last

Parent or Guardian 2 Address (if different than above)

Street Address Address Line 2 City State ZIP Code

Parent or Guardian 2 Daytime Phone

Parent or Guardian 2 Cell Phone

Parent or Guardian 2 Email

Enter Email Confirm Email

How did you hear about our program?*

Participant's t-shirt size*

Youth t-shirt sizes run small. We are unable to guarantee shirts to those who register after June 15th.

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. NOTE: WE ARE UNABLE TO HONOR GROUP REQUESTS. THIS SPACE IS FOR MEDICAL INFORMATION ONLY.

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*

Price per camper

Total

$0.00

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Product Name