STARBASE 2018 Indianapolis Summer Camp Programs. This packet contains all the forms necessary to apply.

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1 1 STARBASE 2018 Indianapolis Summer Camp Programs. This packet contains all the forms necessary to apply. All Indianapolis camp programs run from: 9:00 AM - 2:30 PM. Parents/guardians and friends are encouraged to attend graduation! Traditional Camps are limited to students entering 5 th 7 th grade in the fall of Advanced Camp is limited to previous campers entering 6 th 8 th grade in fall of Advanced 2.0 Camp is limited to previous advanced campers entering 7 th 9 th grade in the fall of There is NO COST for the camp, but parents must provide transportation to and from the daily camp location. There will be a possibility that camps will not be at the same location each day (More information closer to camp dates). We ask that parents/guardians provide lunches, water, sunscreen, etc. for your camper. ** Space is extremely limited! Weeks will be filled on a first-come, first-served basis for all sessions. ** Young Inventors - Traditional Camp: Campers who have never attended STARBASE camps will be placed first. Those who have attended STARBASE camps may still register and will be added to slots after newcomers. Additional applications will be added to a standby list and you will be contacted ASAP if a space becomes available. Explorations - Advanced Camp: Campers must have attended a STARBASE Indiana Indianapolis Traditional Summer Camp to attend. Robot Evolution Advanced 2.0 Camp: Campers must have attended the 2017 STARBASE Indiana Indianapolis Advanced Summer Camp to attend. Please see the attached registration form or visit Accepted students will receive additional materials prior to the camp dates. All notifications will be made by whether you have been accepted or not. Inquiries please Registration for the 2018 STARBASE Indianapolis STEM camps open at 10:00am on Thursday, March 1 st, 2018 and close when the camps are full. Early applications will not be accepted, be sure to mark your calendars to register for the following: Young Inventors Traditional Camp Camp Dates: Camp 1: June (Monday Friday) Camp 2: July (Monday Friday) Explorations Advanced Camp Camp Dates: Camp 1: June (Tuesday - Friday) Robot Evolution Advanced 2.0 Camp Camp Dates: Camp 1: July (Tuesday Thursday) *Campers can register for 1 camp per summer only 2018 Indianapolis Summer Camp Registration

2 These forms must be completed and submitted to STARBASE Indiana - Indianapolis. 1. Application Information & Emergency Information 2. Release of Liability / Hold Harmless 3. Photographic / Public Affairs Release 4. Camper Code of Conduct 5. Camper Pick-up Consent Form 6. Camper Demographics 7. Chaperone Statement of Voluntary Participation (Only required if you want to volunteer) Please check which summer week your child would like to attend. You may indicate your 1 st and 2 nd choice: Young Inventors Camp Traditional Camp Camp 1: June 18-22, 2018 Mon Fri Camp 2: July 16-20, 2018 Mon Fri Explorations Camp Advanced Camp (Remember you must have attended a 2017 STARBASE Indianapolis camp to attend) Camp 1: June 26-29, 2018 Tue Fri Robot Evolution Camp Advanced 2.0 Camp (Remember you must have attended a 2017 STARBASE Indianapolis Advance Camp to attend) Camp 1: July 10-12, 2018 Tue Thurs Please indicate which STARBASE program(s) (if any) your child has already participated in: STARBASE 1.0 the 5-day program for 5 th grade classes STARBASE Summer Camp - What Year(s): What Camp(s): Submit completed and scanned application forms by to: Mail forms to (please send an to let us know what date you mailed it on): STARBASE Indiana - Indianapolis Attn: Summer Camp Application 2002 South Holt Road Bldg. 15 Indianapolis, IN Please indicate if the child you are registering has parents serving in the military. Yes No If yes, which branch Indianapolis Summer Camp Registration

3 STARBASE Camp Application Page 1. School: Teacher: Form Due Date: STARBASE Indiana Indianapolis at the Joint Force Headquarters, Stout Field Indiana National Guard Base 2002 S. Holt Rd., Indianapolis, Indiana Phone: and ***PLEASE PRINT CLEARLY AND COMPLETE ALL INFORMATION. CAMPER MAY NOT ATTEND STARBASE UNLESS FORM IS SIGNED*** Camper/Parent/Guardian Information: Camper Name: Gender: Male Female Grade (entering in fall 2018): Parent/Guardian Name(s): Home Phone: Parent/Guardian Cell Phone: State: Birth Date: Zip: Work Phone: Emergency Information (necessary for treatment in a medical emergency): Emergency Contact Name: Relationship to Camper: Home Phone: Cell Phone: Work Phone: _ Insurance Carrier: _Policy #: *Please note any medical conditions, concerns or other special issues which a chaperone should be aware* Release of Liability/Hold Harmless: This release of liability made by the undersigned, a parent or guardian of a potential participant in the STARBASE Indiana Program (hereinafter collectively referred to as Applicant ), for the purpose of releasing the U.S. Government, Indiana Department of Military and Veterans Affairs, the Department of Defense, the Indiana Air National Guard, National Guard, STARBASE Indiana Inc., and STARBASE, STARBASE, sponsoring agencies, and its staff or representatives liable in any way should injury/death or disability result from my participation at STARBASE. I take full responsibility for any damage that might occur to government/starbase property caused by myself and/or applicant. WHEREAS, the said camper desires the use of services, grounds, facilities and/or equipment of the STARBASE Indiana program for participation in the STARBASE Program does hereby state that: In consideration of the mutual, advantages, benefits and purpose to be achieved thereby; the use of said grounds, facility or equipment for the purpose and activities described is hereby approved, conditioned upon the applicant releasing the Indiana National Guard and its agents, servants, employees, soldiers and airmen of and from any and all claims, demands, actions, causes of action whatsoever, arising out of or related to any loss, damage or injury, including death, that may be sustained by any person or property arising out of the described activity or any other activities relating thereto conducted by Applicant or en route to or from these activities. The applicant understands and agrees that there are certain risks attendant to these activities and by signing this agreement expressly authorizes travel to and from the various activities in Indiana National Guard vehicles. The applicant individually and on behalf of the minor child hereby expressly and voluntarily assumes all risks and hazards of injury to the minor child and his or her property resulting from participation in the program to the full extent allowable under federal and state law. In the event of accident, injury, or other medical emergency, STARBASE Indiana is authorized to make emergency medical decisions on behalf of Applicant and to release STARBASE Indiana from liability for same. I understand that my liability for property damage and personal injuries caused by my child is the same as I am subject to during normal school hours and activities at my child s school. Applicant understands the above terms and conditions and acknowledges that he/she has carefully read the above statement and willingly complies with the terms and conditions thereof, understanding that he/she voluntarily assumes all risks and hazards of injury to applicant resulting from participation in the described activities. Parent/Guardian Signature: Parent/Guardian Printed Name: Date: Photographic/Public Affairs Release (Must fill out one per child attending): I hereby authorize STARBASE Indiana, the Indiana National Guard, the United States Department of Defense, the STARBASE Program, and sponsoring affiliates and other federal and state governmental entities and corporations working in conjunction therewith to utilize photographs of my child for promotional purposes. I hereby waive any monetary or other rights that I might have to inspect and/or approve the finished product of the advertising, promotional or news copy and consent to its use in whatever way STARBASE Indiana, Indiana National Guard deems appropriate. I hereby consent to the release of said photographs to broadcast and print media such as non-governmental newspapers and publications, television, cable or radio stations. I understand that the all rights and title to the released information shall remain with STARBASE Indiana, Indiana National Guard or the recipient. Parent/Guardian Signature: Parent/Guardian Printed Name: Date:

4 STARBASE Camp Application - Page 2. PARENTS - PLEASE READ THIS OVER WITH YOUR CHILD AND SIGN BELOW YOUR ACKNOWLEDGMENT. You are about to embark on an exciting educational STEM experience. However, to get the most from the unique opportunity, your conduct is very important. Your participation in STARBASE means you agree to the following Code of Conduct: I will be on my best behavior. I will come each day prepared to learn. I will participate in all camp activities while at STARBASE. I agree to not use my cell phone during camp hours, unless approved by STARBASE staff. I will be a good listener and raise my hand to speak. I will not travel to any location without my STARBASE volunteer or STARBASE staff member. At all times, I will remember to stick with the group. I will address others by their proper name or approved nickname. I will be courteous to and respectful of authority and other campers. I know my rights end where my neighbor s rights begin. I will consider this before I do or say something which may offend another. If a camper is sick, injured, or is being mistreated in any form, I will notify a STARBASE staff member immediately. I understand that profanity, vulgarity, and other similar forms of inappropriate conduct will not be tolerated under any circumstances. Any offensive touching or hitting (fighting) will, likewise, not be tolerated. I understand that there are some actions that will not be tolerated because they are harmful or against the law. Therefore, I understand that I will not be allowed to participate in the STARBASE program for bringing weapons, alcohol, tobacco, or other illegal drugs and items. I will wear appropriate clothing for the predicted weather. (Some activities are conducted outside) When in doubt, I will ask my STARBASE volunteer or a STARBASE staff member. I will bring my own lunch and drink for each visit. My Camper promises to follow all the rules and directions given to them by STARBASE. They understand that any failure to follow this Camper Code of Conduct may result in disciplinary action being taken against them, up to and including dismissal from the STARBASE program. By signing below, I agree that the above outlined code was thoroughly explained to my camper and they agree to follow the code of conduct. Parent/Guardian s Signature: Parent/Guardian s Printed Name: Date: STARBASE Indiana-Indianapolis at the Joint Force Headquarters, Stout Field Indiana National Guard Base 2002 S. Holt Rd., Indianapolis, Indiana Phone: and

5 STARBASE Camp Application Page 3. I, (Parent/Guardian s name) hereby give permission to the following adults below to drop off or pick up my camper at STARBASE Indiana Indianapolis during the Summer camp I have signed them up for. All adults must show their license when picking up your camper. If their name is not on our list, your camper will not be allowed to leave with them. Please include your name below as well as any family members and friends (example: Spouse, siblings, grandparents, family friends, nannies). First and Last Name Relationship to the camper Parent/Guardian Signature: Parent/Guardian Printed Name: Date:

6 STARBASE Camp Application Page 4. CAMPER DEMOGRAPHICS STARBASE admits campers of any race, color, national and ethnic origin to all the rights, privileges, programs, and activities generally accorded or made available to campers at STARBASE. It does not discriminate on the basis of race, color, national and ethnic origin in administration of its educational policies and admissions policies. RACIAL/ETHNIC STATUS: Per the outline in Standards for Maintaining, Collecting, and Presenting Federal Data on Race and Ethnicity, please check the appropriate category for your camper AMERICAN INDIANA or ALASKA NATIVE ASIAN HISPANIC or LATINO NATIVE HAWAAIIAN or OTHER PACIFIC ISLANDER BLACK or AFRICAN AMERICAN WHITE or CAUCASIAN OTHER Please identify the appropriate category that apply to your camper: INNER CITY (more than 2,500 people) RURAL (less than 2,500 people)

7 STARBASE Camp Application Page 5. CHAPERONE STATEMENT OF VOLUNTARY PARTICIPATION Please Note: All CHAPERONES must completely fill in the information on this form to volunteer at STARBASE Indiana Indianapolis. Please also note that we can only have up to three chaperones each day of your campers visit to STARBASE due to limited room. If you would like to volunteer, please fill out this form completely and let us know which dates you are available. Once all paperwork is in we will if you have been selected to volunteer and on which day(s). Please Note: The statement following is legal and binding. Do not alter or modify in any way. I acknowledge that I am voluntarily choosing to participate in STARBASE. I also acknowledge that I have been informed of the risks involved in such activity. Furthermore, I agree not to hold the U.S. Government, Indiana Department of Military and Veterans Affairs, the Indiana National Guard, STARBASE Indiana Inc., and STARBASE, STARBASE SUMMER CAMP, sponsoring agencies, and its staff or representatives liable in any way should injury/death or disability result from my participation at STARBASE. I take full responsibility for any damage that might occur to government/starbase property caused by myself. CHAPERONE SIGNATURE DATE PRINTED NAME AS ON DRIVER S LICENSE DOB (MM/DD/YYYY) DRIVER S LICENSE NUMBER STATE ISSUED CAMPER NAME Dates available to volunteer:

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