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    Youth S.T.E.A.M. Camp Application 2020 Page 1

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    Parent/Guardian/Foster Care Information:

    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 online 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 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 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 the Virtual Summer Camp 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.

    School Records Release Statement
    I give my consent for my son’s/daughter’s/ward/’s school records to be accessed by the selected community based
    organization and the Kids Hope Alliance through the Duval County Schools Student Information Management System
    (SIMS) for the purpose of gathering data for analysis of program effectiveness. The data accumulated will be aggregated
    without identifying any individual child.

    Parent/Guardian is responsible for connecting the devices to virtual classroom daily.
    Failure to comply may result in participant being removed from the program.
    Dear Parent/Guardian:
    To assist in ensuring your child’s well-being while attending Summer Camp Program, please complete and return
    immediately.

    STUDENT HEALTH FORM
    ​

Submit

    Youth S.T.E.A.M. Camp Application 2020 Page 2

    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. 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.
    Sibling Notification Form: (this form helps us identify siblings for program placement.)
    Please submit both pages of the form.
Submit
Please submit both pages of the form.
Picture
Shiva robotics academy is an educational institut​ion that teaches kids about Science, Technology, Engineering and Mathematics through various hands-on activities.
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  • About Us
    • Our Story
    • Former Leadership
    • Staff
    • Awards
    • Media Kit
    • Press
    • Gallery
    • Testimonials
    • Partners and Sponsors
    • Franchising
    • Join our Team
    • Internship
    • Contact Us
  • Programs
    • Virtual
    • Weekly Class
    • Homeschool LEGO Robotics Class
    • SUMMER CAMP
    • Junior Team
    • Senior Team
    • TECH Team
    • High School Team
    • Robotics Workshop
    • Birthday Parties
    • School Field Trips
  • Application
  • Online Store
  • FLL Explore Expo Registration
  • SummerVPK
  • Blog
    • Shiva Atomatrons
    • FIRST LEGO League Challenge Teams
    • FIRST LEGO League Explore
    • SHIVA Success Stories