0920-0729 Att E Registration Form

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

National Center for Health Statistics

Data Detectives Summer Camp 2016

Camp Registration Form

Notice-Public reporting burden for this collection of information is estimated to average 30 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).

(For Parents of Accepted Students)

If accepted, additional forms to be filled by parent/guardian may include…

Parent / Guardian 1 and 2 information

Name of person who will be picking student from camp daily

­­­ ___________________________ ___________________________

Last Name First Name

­­­ ___________________________ ___________________________

Relationship to Student Phone Number

Optional: Name of second person who will be picking student from camp

­­­ ___________________________ ___________________________

Last Name First Name

­­­ ___________________________ ___________________________

Relationship to Student Phone Number

Alternative Contacts

In the event of an emergency, I authorize the following individuals to pick up my child from the program

­­­ ___________________________ ___________________________

Name / Relationship Phone Number

___________________________ ___________________________

Name / Relationship Phone Number

Please provide any additional information about your child that we should know during his / her attendance at the camp. Include any special needs, important medical history / behavior and / or accommodations needed): ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Photography Release

I grant permission for CDC staff to take pictures or video of my child to be used for marketing purposes without compensation or time limitations.

___________________________

Parent / Guardian Signature

Acceptable Behavior Policy

It is important that all campers receive a positive and rewarding experience while attending our program. In order to ensure a safe and fun environment for all, children are expected to behave in an acceptable manner and use appropriate language. ANY behavior deemed to be detrimental to or in violation of camp standards will be dealt with by the staff. Unacceptable behavioral instances include, but are not limited to: any form of intended harm to another camper or staff member, bullying or any form of aggression.

I have read and will abide by the camp rules. I understand that camp staff have the right to remove any person from the program that does not abide by these rules.

___________________________ ___________________________

Parent / Guardian Signature Child Signature

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