Please provide cell phone number.

Youth's First Name

Youth's Last Name

Youth's Date of Birth Month/Day/Year

Youth's T-shirt Size

Please indicate which school the participant attends or organization in which he/she is affiliated.

Photo Release I, the undersigned, do hereby consent to the use by The Board of Trustees of the University of Illinois (“University”) of my image, voice, or both described below, in (1) the video, photograph, or audio recording described below; and (2) any video, photograph, or audio recording reproduced either in whole or in part from the video, photograph or audio recording described below: regardless of whether these materials are used for fundraising, advertising, publicity, or any other purpose on behalf of either the University or its Foundation. I warrant that I have the full right and authority to grant this consent. In addition, I waive all claims to compensation or damages based on the use of my image or voice, or both, by either the University or the Foundation. I also waive any right to inspect or approve the finished photograph or video or audio recording. I understand that this consent is perpetual, that I may not revoke it, and that it is binding on me, my heirs and assigns. I warrant that I am at least 18 years of age and that I am competent in my own name insofar as this consent is concerned, or that I am the parent or legal guardian authorized to sign on behalf of a person under age 18. I further attest that I have read this consent form and fully understand its contents.

Youth's Grade Level

Please tell us how you learned about this camp opportunity.

Registration

I would be willing to contribute to a scholarship for a participant to attend STEM Camp. We offer scholarships to girls who the cost of the camp is a financial burden. If you would be willing to donate a portion of the fee for one of these scholarships, please indicate the amount below.

What else would you like us to know? (food allergies, medical conditions, accommodations, etc.)