Astro Camp - Registration Application

Astro Camp® will be held at Infinity Science Center, located at 1 Discovery Cir, Pearlington, MS 39572. (Payments and registration forms should not be mailed to this address see address below.)

Total tuition cost for Astro Camp is $140 per camper. Astro Camp/Stars tuition, in part, covers the cost of the materials used in the course of the camp, including daily meals and snacks, t-shirts, camp journals and consumables for hands-on activities.

Please make check or money order payable to NVision Solutions, Inc.

The registration application, check and all related forms should be mailed to:

NASA Stennis Space Center

Office of Education Attn: Nvision Solutions, Inc./ASTRO CAMP Roy S. Estess Bldg. Room 108 Stennis Space Center, MS 39529-6000

Registration forms may only be mailed; they may not be hand delivered.

If you have questions, please call the NASA Education Office Astro Camp Line at 228-688-3485, or 1-800-237-1821 (Option 4).

First Day of Camp Processing - MONDAY - 8:00 a.m. All parents and campers must report to the Astro Camp Infinity Science Center for day-one drop off, followed by parent orientation held at 8:35 a.m. Camp hours are 8:00 – 3:30 daily.

Please circle only one session of camp (offered by grade/date). Grade level refers to grade the child will be entering in the fall:

Astro Camp 2nd – 4th Graders Astro Camp 5th – 7th Graders STARS 8th – 10th Graders June 5-9, 2017 June 5-9, 2017

June 12-16, 2017 June 12-16, 2017 June 19-23, 2017 June 19-23, 2017

June 26-30, 2017 June 26-30, 2017 July 10-14, 2017 July 10-14, 2017 July 17-21, 2017 July 17-21, 2017

Camper’s Name: _________________________________________________________ Age: ________

Mailing Address: _______________ ____________

City/State/Zip:

Parent’s/Guardian’s Name

Daytime Phone: ( ______) ____Evening Phone: (_______) __________________

Email: ____________________________________________

Please circle T-shirt size: Youth M Youth L Adult SM Adult M Adult L Adult XL NOSL- Astro Camp Summer 2017 1

Parent Authorization

Camper’s Name: ___________________________________________________________________________

Age: ___________ Camp Dates: _____________________________________________________________

Parent / Guardian Name(s): __________________________________________________________________

Parent / Guardian Daytime Phone: ________________________ Alternate:__________________________

Email (optional) please print - _______________________________________________________________ Email will be used to send notification of upcoming camps and communication during camps. ASTRO CAMP BEHAVIOR POLICY The Astro Camp staff strives to ensure that every camper has a safe, fun and meaningful experience. Instances of unsafe behavior or misconduct, or failure to follow the directions of the staff, detract from this experience. Flagrant or repeated misbehavior will result in removal of a camper from the camp session. Upon removal from camp, readmission will be evaluated on a case by case basis, and only after a parent/staff conference. PARENTAL AUTHORIZATION

News Release As a camp participant, your child may have their photo and/or name included in our news releases or NASA website. By registering your child and completing this form, you acknowledge and authorize this action.

Camper Release To assure the protection of Astro Camp participants, please provide the name and relationship of the individuals who have your permission to pick up your child. Your child will not be released without this permission. The camp supervisor/coordinator must be notified as soon as possible for early release. Forms will be provided during camp for parents’ to place additional persons on the approved permission list for child pickup. By signing this, you acknowledge that your child will not be considered as delivered into the safekeeping of Astro Camp personnel, unless the child is delivered directly to personnel at the check in table on the second floor of Infinity.

Transportation to Events Children will be transported to events at Stennis Space Center or Michoud on NASA/Infinity tour busses. If a child becomes ill, it may be necessary for personnel to transport the child to the clinic on Stennis Space Center along with any medical information provided about the child. If a child is transported to the clinic, the parent/guardian will be notified as soon as possible. By signing this form you acknowledge and authorize that under these circumstances, your child will be transported away from Infinity Science Center. ________________________________ __________________________________ Name Relationship to Child ________________________________ __________________________________ Name Relationship to Child I hereby acknowledge and authorize all of the statements above. SIGNATURE OF: ____________________________________________________ Date: ____________ PARENT / GUARDIAN

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RELEASE/CONSENT FORM Stennis Space Center

Please print name:___________________________

[Please read the following consent statement and sign below.]

I hereby consent, release and provide permission to NASA’s Stennis Space Center to use (in full or in part) all photographic and videotape images taken of me and/or audio recordings made of my voice without consideration or compensation. The images/recordings captured may be used in brochures, news releases and other types of venues and materials to promote NASA’s programs.

I hereby consent:___________________________ ________________ PLEASE SIGN YOUR NAME HERE

Date: ___________________________

Witness sign here: ___________________________ __________

Note: If person being photographed or videotaped is a minor, please complete the following information.

Parent or Legal Guardian: _______ . PLEASE PRINT AND SIGN YOUR NAME

Address:

State:_____________________________ City:_______________________ Zip Code:______________

Date of Legal Guardian Signature:____________________________________________________________

If you are with a school or other group, please provide the name of the group and contact person’s name and number:

__________________________________________________________________________________________

On behalf of Stennis Space Center, thank you for your continued support and participation in our museum,

programs and services. For more information, visit our Web site at http://.ssc.nasa.gov/public/visitors.

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Astro Camp - Health and Medication Policy

Health Policy

Children who are unable to participate in the day’s activities should not be in attendance. This may be a

hardship on families, but is necessary for the health and safety of staff and all campers. If a camper is sent

home from Astro Camp due to illness, instructions will be given to the parents regarding return.

Health and Care Guidelines

1. Children who appear ill on arrival to any camp session including rash, vomiting, diarrhea, fever, red eyes

with mucous discharge, or who may be experiencing signs of a communicable ailment, cannot be admitted to

the program without written clearance from a physician stating that the child is cleared to participate and is

not contagious.

2. Children who become ill during the course of the day with any of the above symptoms, or other serious

indicators of illness, must be checked out of camp by a parent at the earliest feasible time, but no later than

two (2) hours after a parent has been notified. Failure to do so will result in disenrollment from the program.

3. The Astro Camp staff may transport the camper to the nearest medical clinic if immediate treatment is

required.

An Astro Camp Medical Release and Consent Form must be completed, signed by a parent or guardian

and submitted at registration to authorize Astro Camp staff to transport a child to a medical clinic.

4. All parents will be notified if the Astro Camp staff becomes aware that a camper has exposed others to a

communicable disease.

5. Children with special needs will be accommodated whenever possible. Before registering a child, parents

should consult with the Astro Camp staff if a special need exists. A statement from a physician must be

submitted specifying the special needs of the child.

If at all possible, parents should adjust medication schedules so that the Astro Camp staff are not responsible

for administering medications during camp. If no other alternative exists, the decision to administer

medication will be on a case-by-case basis. This decision will depend on the following conditions:

Only topical, oral, or inhaler medications will be routinely administered.

Emergency or “rescue” medications (such as epipens or asthma inhalers) will be kept in the same

location as a camper, but will only be utilized in the event of a medical crisis. Parents will be notified as

soon as possible after such medication is administered.

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Medication Administration Process

Prescription medicines and over-the-counter topical medications may be administered by the Astro Camp

Staff if the following conditions are met:

1. Medication must be in original bottle/container. Containers for medications must have child-resistant

packaging.

2. Packages for medication must include original pharmacy label. The pharmacy label will include the child’s

first and last name; date prescription filled and expiration date; name of health care provider; instructions for

administration (dosage, frequency) and storage; name and strength of medication must appear on the

bottle/container of all prescription medications.

An Astro Camp Medication Authorization Form must be completed and signed by a parent or guardian

and submitted at registration before any medications can be administered. Staff will log all

medications given on the medication form.

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Astro Camp Medical Release and Consent Form

Child’s Name:______________________________________________________________________________

Parent’s Name (same listed on registration):_____________________________________________________

Medical Release In the event of a medical emergency, I hereby authorize Astro Camp medical personnel designee to treat my child, who may be transported to the nearest medical facility, including a Medical Clinic. I also hereby confirm that I have read and will comply with the “Camper Health and Medication Policy.”

Please complete the Medication Authorization Form if medication is required.

Parent / Guardian Name: _____________________________________________________________________

Parent / Guardian Signature:__________________________________________________________________

Phone: (_____) _____________________________ Alternate Phone: (______) ________________________

Date: _____________________

Alternate Emergency Contact:

Name: _____________________________________________ Phone: (______) _________________________

Relationship to child: ______________________________________________________________________

Name: _____________________________________________ Phone: (______) ________________________

Relationship to child: _______________________________________________________________

Health Information In order to ensure your child's educational needs are met, please provide us with any information that would help us accommodate your child. (For instance, Astro Camp involves group and individual activities that may result in loud unexpected noise that could over stimulate some children.)

Use the space below to provide any information regarding chronic illness, allergies, or any other health or behavior information that may be helpful in assessing or treating your child in case of illness or emergency. Please be as thorough as possible; attach a separate sheet if necessary.

__________________________________________________________________________________________

__________________________________________________________________________________________

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Astro Camp Medication Authorization Form

Child’s Name:__________________________________________________________________

(Please use separate sheet of paper to list more medications)

To be completed by Stennis medical staff only. Date Administered Personnel Dispensing Medication Time Dosage Given

Name of Medication ____________________________ Prescription ____ OTC ____ (check one)

Inclusive Dates – Begin: __________________________ Finish: ________________________________

Dosage: _______________________________________ Time: _________________________________

If prescription medication, please list name of authorizing physician.

Authorizing Physician:_____________________________ Phone number: ______________________

Name of Medication ____________________________ Prescription ____ OTC ____ (check one)

Inclusive Dates – Begin: __________________________ Finish: ________________________________

Dosage: _______________________________________ Time: _________________________________

If prescription medication, please list name of authorizing physician.

Authorizing Physician:_____________________________ Phone number: ______________________

Parent Signature:___________________________________________________ Date:__________________

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Astro Camp Parental Authorization

for

Additional Transportation Release

Child’s Name:______________________________________________________

Parent’s/ Guardian’s Name____________________________________________________________________

Parent’s/Guardian’s Contact Phone_____________________________________________________________

Dates _____________________________________________________________________________________

The individuals listed below have permission to drop off or pick up my child from Astro Camp at Infinity

Science Center. By signing this, you acknowledge that your child will not be considered as delivered into the

safekeeping of Astro Camp personnel, unless the child is delivered directly to personnel at the check in table

located inside Infinity Science Center. All Astro Camper’s must be signed out each afternoon to the Parent,

Guardian or specified individual listed below on the second floor Astro Camp reception desk. Identification is

required. Additions to the list must be made in person by the Parent/Guardian in writing. Telephone calls

cannot be accepted.

Individual Name Contact Number

1.___________________________________________________ _____________________________

2.___________________________________________________ _____________________________

3.___________________________________________________ _____________________________

4.___________________________________________________ _____________________________

5.___________________________________________________ _____________________________

6.___________________________________________________ _____________________________

Parent Signature:____________________________________________________________________________

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