Youth STEAM Camp

Through our non-profit initiative, Shivaji Foundation, we provide economically accessible robotics classes for students from underrepresented communities.
We’d love to welcome your child into this program! Please take a few minutes to complete this form to see if your child qualifies for this opportunity.

Economically Accessible Robotics Course Application

* Indicates required field

Student Name *

Grade Level *

Gender *

Date of Birth *

Race/Ethnicity *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Student Shirt Size *

Total Household Income *

Parent/Guardian/Foster Care Information:

Name *

First

Last

Address (You can leave blank, if same as above) *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Cell/Work Phone Number *

Family Arrangement *

Person(s) authorized to be contacted *

Mother Father Both Neither

person authorized to be contacted in case of an emergency *

Address (You can leave blank, if same as above) *

Line 1

Line 2

City

State

Zip Code

Country

Relationship *

Phone Number *

Physician Name *

Physician Phone Number *

Does your child have any special medical needs? *

Yes No

If yes, please specify *

Does your child have a history of chronic illness or any behavioral issues, or legal history? If so, please specify *

Does your child have any allergies? If so, please specify. *

General Release of Liability:
In consideration of being allowed to participate in any way in the Program and related events and activities the undersigned agrees to the following: I acknowledge and fully understand that each participant will be engaging in activities that may involve risk or serious injury; including permanent disability and severe social and economic losses, which might result not only from their actions, inactions or negligence, but the action, inaction or negligence of others, the rules of play or the condition of the premises or of any equipment used. Further, that there may be risks not known to us or not reasonably foreseeable at this time. To the best of my knowledge, my daughter/son is physically fit to engage in the activity in question. I understand that the Duval County School Board, the Kids Hope Alliance, Shiva Robotics Academy, Shivaji Foundation, Florida State College at Jacksonville and the selected community based organization
and their employees and agents will exercise reasonable care while my daughter/son is in their custody and care engaging in activities through the Program. I agree to hold the Duval County School Board, the Kids Hope Alliance, Shiva Robotics Academy, Shivaji Foundation, Florida State College at Jacksonville and the selected community based organization and its employees and agents harmless from any and all liability, which may arise while exercising their duty of care, relating to my daughter/son for personal injury or illness that may be suffered or any loss of property that may occur to my daughter/son while participating in this Program.

Authorization for Emergency Care:
In case of accident or serious illness, and the school/program is unable to reach me, I hereby authorize the school/program to contact the physician indicated on the application and to follow his/her instructions: If it is impossible to contact this physician, the school may make whatever arrangements necessary to provide care and treatment for my child. In case of accident/serious illness where the immediate treatment of my child is not necessary, but he/she is unable to remain at school, the school/program will contact me or arrange transportation for my child. If the school/program is unable to reach me, I authorize the school/program to contact one of the persons indicated on the enrollment form.

Photo/Media Release:
I acknowledge and understand that publicity activities such as interviews, photos, and videotaping may occur. I consent and
permit my child, as a participant in the Summer Camp Program and events, to be photographed, videotaped, and/or
interviewed for publicity activities.

I consent to my personal information being collected and processed in accordance with the organization's Privacy Policy *

YES

I affirm that anytime I submit data to SHIVA/SHIVAJI on behalf of another person, I shall obtain and maintain a record of all required legal consents before collecting or submitting any such data. *

YES

I understand and acknowledge that by attending the class/camp/event/activity I will be subject to audio and video recordings, photography, and public broadcast, and that the voice and likeness of attendees, volunteers and participants may be collected and used as a record of the event and for the non-commercial promotion of SHIVA/SHIVAJI *

Yes

(Application is not considered complete unless signed below to indicate agreement with all of the above.) Parent/guardian signature *

Date of Signing *

Submit

Economically Accessible Robotics Course Application

Parent/Guardian/Foster Care Information:

Stay connected & receive our special Promo Codes!

TESTIMONIALS

Need help? Contact us!

Telephone

Email

Contact Us

About Us

Programs

Online Store