Parent Application

Attachment B OMB No. 0920-1185 Exp. Date 05/31/2020

National Center for Health Statistics

Data Detectives Summer Camp

NOTICE - Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the 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 currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: CDC/ATSDR Information Collection Review Office; 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-xxxx).

Assurance of Confidentiality - We take your privacy very seriously. All information that relates to or describes identifiable characteristics of individuals, a practice, or an establishment will be used only for statistical purposes. NCHS staff, contractors and agents will not disclose or release responses in identifiable form without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m(d)).

Parent Application Form

 

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

Current Grade Level: 5th grade, 6th 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.

What is your child’s current statistical / math knowledge and interest?

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What would you like your child to gain from this camp? What are your expectations of this camp? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

____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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