GAC-HAB2017 Registration Form Your Information First Name Required Last Name Required Address Required City Required State Required Zip Required Primary E-mail Address Required Phone Required Date of Birth Required Grade (Fall '17) Required Sex Required Male Female Parent/Guardian's First Name Required Parent/Guardian's Last Name Required Parent/Guardian's Email Required Parent/Guardian's Phone Required Science/Math Teacher Name Required Science/Math Teacher E-mail Required School and Address Required T-shirt size Required - please select - S M L XL XXL Tuition Payment Required Please select one of the following payment options. Full Registration $750.00 Full registration amount, including the $100 non-refundable deposit Non-refundable Deposit $100.00 The remaining balance is due June 25. Additional Deposit 1.00 If you would like to pay an additional amount on your deposit at this time please specify the amount you would like to add. Your additional amount and $100 non-refundable deposit will be deducted from the full registration to determine your remaining balance. $ Releases Transportation With Institute Staff Our policy is that enrolled students should never leave the Gustavus campus unless accompanied by an Institute Staff memeber. As part of our enrichment program, staff members will sometimes arrange local trips for students. Your signature below indicates your permission for your child to be transported in a fleet vehicle or private automobile driven by a staff member within an 80 mile radius. I agree to the terms of transportation. Required Permission to Leave Campus We take our responsility for enrolled students very seriously. We foresee no reason for any student to leave campus without the supervision of a staff member. If, however, there is a specific reason (such as visiting a relative) for the student to leave campus, please indicate below. We cannot honor blanket permissions. My child will need to leave campus. Times child will be off campus Please include destination address, purpose, time departing, and times returning. You can specify multiple trips. Vehicle Information If you plan on brining your own vehicle, we need to know. We must insist that students not use their vehicles during the duration of the camp. Failure to comply with this rule will be considered a serious breach of the camp's rules and may be grounds for the student being asked to leave the camp. We plan to bring our own vehicle. Make Model Year State License Number General Liability Waiver Though Gustavus makes every effort to ensure the saftey & supervision of students attending a Gustavus Summer Academic Program, participants must abide by Gustavus rules and regulations. Gustavus will not accept responsibility for actions or injuries to or by students incurred while violating Gustavus rules and regulation, or local, state, or federal laws. I agree to the general liability waiver. Required Medical Information Emergency Contact Name Required Emergency Contact Phone Required Health Insurance Provider Required Health Insurance Policy Number Required There is a medical condition or medication Gustavus should be aware of. Physician's Name Physician's Number Medical Condition(s) and/or Medication(s) Photo Release Gustavus Adolphus College Summer Academic Programs, in conjunction with the College, would like to use pictures taken during the camp in future publicity materials. In order to do so, we need consent. I agree that my photo may be used for promotional material. Required Airport Transportation Information Arrangements can be made with Land-to-Air, Mankato or 507-625-3977. Gustavus is one of the Land to Air drop off sites. Submit You will be charged .