GAC-SSI2015 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 Age Required Grade (Fall '15) 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 Coach Name Required Coach E-mail Required High School and Address Required T-shirt size Required S M L XL XXL Event Focus Please select your one event of focus Required Prose Humorous Poetry Oratory Creative Expression Storytelling Dramatic Duo Extemp Speaking Informative Extemp Reading Drama Great Speeches Tournament History Please provide a one-page summation of your speech competition experience and awards. Required Tuition A $150 non-refundable deposit is due at the time of registration. A $100 deposit for MN Summer Academic Enrichment Program. Registration received by June 1st $725 (Early Registration Rate) Registration received by June 15th $750 (Group of 4 or more)$800 Champions Extension $350 (In addition to tuition) Payment Required Group of 4 or More $750.00 Full Registration $800.00 Non-refundable Deposit $150.00 The remaining balance is due July 18. MN Summer Academic Enrichment Program Only $100.00 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. $ Additional Payment Options Champions Extension $350.00 None $0 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 locla 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 to restaurants, museums, stores, theaters, parks, or other local attractions 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 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, protection, and supervisiont 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 Flight Information Gustavus Summer Academic Programs offers a shuttle service to and from the Minneapolis-St. Paul International Airport. The fee is $25 round trip. If you wish to utilize this service, please select “$25 shuttle service” below. Due to the number of students attending camps, we can no longer cater towards specific flight times. Note: Students are responsible for exiting the plane and locating the shuttle on their own. A staff member will be waiting at baggage claim, and will be wearing his/her Gustavus ID. Details on shuttle location will be sent out two weeks prior to camp. The arrival shuttle from the airport will depart at 1pm on July 18th. Please book your flight home after 9am on July 26th. **Note: If you are participating in the extension, please book your flight home after 6pm on the 28th. We cannot make extra trips or exceptions. If you wish to fly in or out at a different time, you must find a different source of transportation. Once you have booked your flight, we request that you email your name, flight itinerary for both arrival and departure, and a number we could use to contact you while you travel to firstname.lastname@example.org at least 2 weeks prior to the first day of camp. Are you flying in? Required Yes, I will be flying in and I would like to take the shuttle. $25.00 Yes, I will be flying in, but I will provide my own ride to Gustavus. $0 No, I will not be flying in. $0 Submit You will be charged .