Form 0920-0729 Att B Parent App

Attachment B OMB No. 0920-0729 Exp. Date 05/31/2017

National Center for Health Statistics

Data Detectives Summer Camp 2016

Notice-Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a current valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing burden to: CDC/ATSDR Information Collection Review Office, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0234).

Assurance of confidentiality-All information which would permit identification of an individual, a practice, or an establishment will be held confidential; will be used for statistical purposes only by NCHS staff, contractors, and agents only when required and with necessary controls; and will not be disclosed or released to other persons without the consent of the individual or the establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).

Parent Application Form

 

Applicant Information
Last Name:		First Name:		MI:
Home Address:
City:		State:		Zip:
Birthdate:

Current Grade Level: 5th grade, 6th grade, 7th grade

Gender: Male, Female

T-shirt size: Youth Small, Youth Medium, Youth Large, Youth X-Large, Adult Small, Adult Medium, Adult Large, Adult X-Large

How did you find out about this program?

	School Counselor		Science/Math Teacher
	Internet		Summer Program Fair
			Other (please specify):

Current School Information
Name of School:

School Town/City:

School State: School Zip:

Parent/Guardian Information
Parent/Guardian Name:
Mobile Phone Number:
Daytime Phone Number:
* Email Address:			* Please provide an e-mail address that you check frequently. We will be sending you updates and announcements regarding your application.
	I acknowledge that I am the parent/guardian and by checking this box, I confirm that the information included is accurate to the best of my knowledge.

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