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Lee’s Summit North Broncobots
Elementary Summer Camp
To be registered for camp, you must mail the following information by May 29th, 2015 to:
Hillary Griffith
901 NE Douglas
Lee’s Summit, MO 64086
1. Completed registration form
2. Completed health form (on back of this form)
3. Full payment (see below).
Student name: ______________________________________________________________________
School attended (14-15): ______________________________________ Grade: _________________
Parent e-mail address: ________________________________________________________________
E-mail will be our main form of communication
Engineering Camp (Current 1st-3rd Graders)
Camp location: LSNHS
Camp date: June 22-26
Camp cost: $70 (includes 15 hours of instruction,
t-shirt and snacks)
Preferred time of camp (circle one):
9 am – 12 pm
Robotics Camp (Current 4th-6th Graders)
Camp location: LSNHS
Camp times: 9 AM – 3 PM
Camp cost: $165 (includes 30 hours of instruction,
t-shirt, snacks, and lunch Friday)
Preferred date of camp (circle one):
1 pm – 4 pm
T-shirt size (Circle one) YS YM
June 8-12
YL
S
June 15-19
M
L XL
(adult sizes)
Make checks payable to Lee’s Summit North High School
The deadline to cancel and receive a refund is June 8th.
Questions may be directed to the Camp Coordinator
Hillary Griffith at [email protected]
For more information: http://teambroncobots.com/camp/
Medical Release Form
Broncobots Elementary Robotics Camp
Please be specific. Too much information is better than too little.
Student Name ________________________________________ DOB__________________________
Address_________________________________________________Phone______________________
City ________________________________________ State ___________ Zip Code ______________
Parent’s Name______________________________________________________________________
Medical Conditions__________________________________________________________________
__________________________________________________________________________________
Allergies to medications_______________________________________________________________
__________________________________________________________________________________
Allergies to food/pollens______________________________________________________________
__________________________________________________________________________________
Health Insurance Company____________________________________________________________
Company Address___________________________________________________________________
Policy Number __________________________________Group Number_______________________
Mom’s Work #________________________________Dad’s Work #___________________________
Cell #______________________________________/_______________________________________
If parents cannot be contacted, who may we contact in case of emergency?
Name_______________________________________________Phone__________________________
IN CASE THE ABOVE STUDENT NEEDS MEDICAL ATTENTION, I GIVE PERMISSION FOR
MEDICAL ASSISTANCE TO BE ADMINISTERED FOR MY SON/DAUGHTER.
________________________________________________
Parents printed name and signature
__________________________
Date