Governors State University, College of Arts and Sciences
Summer 2017 STEAM Camp Registration Form
This form supports registration in one or more STEAM Camps at Governors State University for Summer 2017. If
possible, please fill out the form and make a payment online and then email, mail, or bring in the completed and
SIGNED registration form as described below.
If paying online via debit or credit card, please complete and submit the registration form online, pay, print the
registration form, complete the physical signature portion and submit. Registration forms may be submitted via
information below.
If paying by check, or cash, please complete the registration form online, submit, print the registration form,
complete the physical signature portion and submit. Registration forms may be submitted via information below.
All checks should be made out to Governors State University.
Registration is not complete until parents and students complete and submit required forms, payment, and
provide required physical signatures. Please maintain a completed copy of this form for your records. Registration
must be completed and received by Friday, July 7, 2017.
Registration form submission
Please submit completed copies of your registration form with parent/ legal guardian signature to:
U.S. Mail
Luke Helm
Attn: STEAM Camp
Governors State University
1 University Parkway
University Park, IL 60484
E-mail
[email protected]
Attn: STEAM Camp
Drop-Off
Luke Helm
Attn: STEAM Camp
Governors State University
CAS Dean’s Office, E2575
1 University Parkway
University Park, IL 60484
Age/Grade Range: middle school, ages 11 to 13 (grades 5 to 8 ); high school, 14 to 16 (grades 9 to 10).
Attire: Participants should wear comfortable clothing and closed-toe shoes. Long hair must be tied back and
jewelry is discouraged. Safety glasses will be provided and must be worn during labs. Participants should be
prepared to walk outside on unpaved paths. Sunscreen and insect repellant are strongly encouraged.
Drop Off/Pick Up: Camp begins at 9 a.m., and concludes at 3 p.m. each day. Participants are highly discouraged
from leaving early.
Registration fee: $200 per week. Fee includes a t-shirt, all materials and a field trip to Bimba Manufacturing.
Registration fee does not include lunch, snacks, or drinks. Please bring a sack lunch, drinks, and snacks or money
for the GSU cafeteria each day.
STEAM Camp Plus: $60 per week. Parents and campers looking for additional activities after 3 p.m. may wish to
enroll in the extra-cost option of STEAM Camp Plus, running from 3 to 5 p.m. Monday to Thursday (note no Friday
STEAM Camp Plus).
Summer 2017 STEAM Camp Registration Form Page 1 of 3
Image release: (A minor is any individual who is 17 years old or younger.)
____________________________________ (student’s full legal name) a minor, and my parent, do hereby give
permission to Governors State University, to use my photograph or photographic image in official university
business, including: university websites, university newsletters and newspapers, etc. I understand that Governors
State University's Legal Department requires that all minors who have agreed to pose for a photograph for use in
the promotion of Governors State University and its departments/units must sign a photograph release form (along
with his or her parent). It is agreed that the use of my photograph or photographic image shall in no way be used
in any other forum other than for official university business.
In consideration of my engagement as a model, and for other good and valuable consideration herein
acknowledged as received, I hereby grant to Governors State University and assigns, those acting with its authority
and permission, the irrevocable and unrestricted right and permission to copyright, in its own name or otherwise,
and use, re-use, publish, and re-publish photographic portraits or pictures of me or which I may be included, in
whole or in part, or composite or distorted in character or form, without restriction as to changes or alterations, in
conjunction with my own or a fictitious name, or reproductions thereof in color or otherwise, made through any
medium at his studios or elsewhere, and in any and all media now or hereafter known for illustration, promotion,
art, editorial, advertising, trade, or any other purpose whatsoever. I also consent to the use of any printed matter
in conjunction therewith.
I hereby waive any right that I may have to inspect or approve the finished product and the advertising copy or
other matter that may be used in connection therewith or the use to which it may be applied.
I hereby release, discharge, and agree to save harmless Governors State University and assigns, and all persons
acting under its permission or authority or those for whom acting from any liability by virtue of any blurring,
distortion, alteration, optical illusion, or use in composite form, whether intentional or otherwise, that may occur or
be produced in the taking of said picture or in any subsequent processing thereof, as well as any publication
thereof, including without limitation any claims for libel or invasion of privacy.
I do hereby release, acquit and forever discharge the State of Illinois, Governors State University, its officers,
employees, attorneys, representatives, insurers and assigns from any and all demands, cause of action and/or
judgments of whatsoever nature of character, past or future, known or unknown, whether in contract or in tort,
whether for personal injuries, property damage, payments, fees, expenses, accounts receivable, credit, refunds, or
any other monies due or to become due, or damages of any kind or nature, and whether arising from common
law or statute, arising out of, in any way, the use of my photograph or photographic image for official university
business.
This release contains the entire agreement between the parties and shall be binding upon and inure to the benefit
of the successors and assigns of the undersigned.
Contact for questions: Luke Helm, [email protected], 708-534-4088
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Camper Information
Student Full Name: ___________________________________________
Address:
Age: _____
Entering Grade: _____
__________________________________________ City: _____________________State: _______ Zip code_________
Student’s t-shirt size: Adult S, M, L, XL, 2X
Parent/ Legal Guardian Information (will be used as Emergency Contact)
Parent/Legal Guardian Full Name: _______________________________________________________________________
Relationship to Participant [check one]
Address:
Parent
Legal Guardian
__________________________________________ City: _____________________State: _______ Zip code_________
Home/cell phone with area code: ______________________ Work phone with area code: ____________________
Additional phone with area code: _______________________
E-Mail Address: ____________________________________________________________________
Please circle those that apply.
Week 1, July 17 to 21, 2017, fee: $200:
middle school
high school
Week 2, July 24 to 28, 2017, fee: $200:
middle school
high school
Week 1, STEAM Camp Plus, 3 to 5 p.m., Monday to Thursday, fee: $60
Week 2, STEAM Camp Plus, 3 to 5 p.m., Monday to Thursday, fee: $60
I understand and agree that GSU will require a physical signature from a parent or legal guardian on various forms
relating to release of liability for the university as a condition of participation in this program, including a field trip
Bimba Manufacturing. I further understand that if my child does not follow the safety procedures, he/she will be
asked to leave the lab.
Reservations are not complete until a student’s completed registration form, liability and photo release form,
payment, and a physical parental/ guardian signature have been successfully completed and received.
Parent/ legal guardian signature: ___________________________________________________
Print
then
Send
then
Date: ______________
Pay Online
Rev. 03.09.2017-2
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