0920-0572 Parent Application Form

Attachment B OMB N. 0920-1185 Exp. Date 07/31/2023

National Center for Health Statistics

Data Detectives Summer Camp

From the Office of Management and Budget (OMB No. 0920-1185 Exp. Date 07/31/2023):

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 (0920-1185).

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)).

Camp Application Form

______________________ ________________________ _________________________

Applicant’s last name Applicant’s first name Applicant’s middle initial

Parent or Guardian Information

This section is to be completed by the parent or guardian of camp applicant.

______________________ ________________________ _________________________

Last name First name Middle initial

Primary phone number: _________________________________________________

Alternate phone number: _________________________________________________

Email address*: __________________________________________________

*Please provide an e-mail address that you check frequently. We will be sending updates and announcements regarding your application.

How did you find out about this camp?

___ School counselor ___ Science or math Teacher ___ Internet ___ Summer fair

___ Other, please specify________________________________________________

What is your child’s current statistical or 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 I confirm that the information included is accurate to the best of my knowledge.

1