0920-0572 Registration Form VIRTUAL

Attachment H OMB No. 0920-1185 Exp. Date 07/31/2023

National Center for Health Statistics

Data Detectives Virtual Summer Camp

Virtual Camp Registration Form

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

(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 listed for emergency contact (if needed)

­­­ ___________________________ ___________________________

Last Name First Name

­­­ ___________________________ ___________________________

Relationship to Student Phone Number

____________________________________________

Email Address

Optional: Name of second person listed for emergency contact (if needed)

­­­ ___________________________ ___________________________

Last Name First Name

­­­ ___________________________ ___________________________

Relationship to Student Phone Number

____________________________________________

Email Address

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

Video Conference Call Attendance Permission

I grant permission for my child to attend video conference calls for the purpose of participating in the 2020 NCHS Data Detectives Summer Virtual Camp.

___________________________

Parent / Guardian Signature

Acceptable Behavior Policy

It is important that all campers receive a positive and rewarding experience while attending our virtual camp. 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 verbal aggression.

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

___________________________ ___________________________

Parent / Guardian Signature Camp Participant’s Signature

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