GenCyber Summer 2022 Student Application

IUP 2022 GENCYBER ADVANCED PROGRAM

STUDENT APPLICATION

ONLINE SUMMER CAMP

JUNE 13-17, 2022

CAMPER INFORMATION

This is a free five-day online camp in the summer of 2022 (daily schedule from 9 AM - 3:30 PM) where students will take part in engaging instruction, group activities, structured discovery, hands-on laboratory experiences, and informal instruction.
Participants in the camp will commit to participating in two pre-camp activity days (3/26/2022 & 5/7/2022) and a post-camp activity day on 9/10/2022.
All pre/post-camp activity days will be held online. Daily schedule from 9 AM - 3:00 PM.
Incomplete applications will not be considered. All requested attachments must be included.
In fall 2022, students must be entering 7th grade or higher to be eligible to apply.
Space is limited, so in cases of comparable qualifications, the earliest application submission will receive preference.
Each student participant will receive an electronic kit as an award for participating in the camp.

First Name *

Last Name *

School District *

Camper E-mail *

Date of Birth *

Gender *

Male Female Non-Binary/Other

Current GPA *

Grade in Fall 2022 *

T-SHIRT INFORMATION

Please Choose Adult or Youth T-Shirt Option *

Adult Youth

T-Shirt Size *

X-Small Small Medium Large Extra Large XXL

APPLICATION CRITERIA

Each candidate student camper needs to obtain the names and signatures of two references (current teachers in the student's school) who know the candidate very well and can recommend that the student be part of this national initiative. Each applicant needs to download the teacher reference form from the link below and ask TWO teachers to complete and sign the form. Completed and signed reference forms must be uploaded to the application site. Space is limited and acceptance will be based on application, qualifications, and recommendations. Selected candidates will be notified by e-mail before the start of camp in early spring 2022 and MUST confirm attendance.

Click HERE to download the teacher reference form.

Please Attach Completed and Signed Teacher Reference Form *

Please Attach Most Recent Grade Report *

GUARDIAN INFORMATION

First Name *

Last Name *

E-mail *

Street Address *

City *

State *

Zip *

Phone Number *

(XXX) XXX-XXXX

EMERGENCY CONTACT

Full Name *

Relationship *

Phone Number *

(XXX) XXX-XXXX

Full Name *

Relationship *

Phone Number *

(XXX) XXX-XXXX

PICK UP APPROVAL (in case of face-to-face camps)

Full Name *

Phone Number *

(XXX) XXX-XXXX

MEDICAL INFORMATION

Dietary Preferences *

Vegetarian Non-Vegetarian

Does your child have any allergies (food, drug, environment)? *

Yes No

Does your child have any chronic illness (heart condition, asthma, diabetes)? *

Yes No

Does your child take any medication on a routine basis? *

Yes No

Will your child require a dose to be given during camp hours? *

Yes No

Comments on any of the previous medical information (type N/A if you answered No to the previous four questions): *

INSURANCE AND PCP INFORMATION

Camper Doctor First Name *

Camper Doctor Last Name *

Camper Doctor Phone Number *

Insurance Company *

Insurance Plan *

Group Number *

Policy Holder First Name *

Policy Holder Last Name *

Policy Number *

In the event of an emergency, I give consent for medical treatment of my child. *

Yes No

PHOTO/VIDEO RELEASE

Please read the following:

I hereby consent to and authorize the use and reproduction by Indiana University of Pennsylvania, or anyone authorized by IUP, of any and all photographs/videos that have been taken of my child in connection with the above-identiﬁed event for any purpose, without compensation to me.

IUP has permission to use their name, likeness and/or image in materials used to promote and market the university in perpetuity.

All negatives and positives, together with prints, slides, digital images, etc., are owned by Indiana University of Pennsylvania.

I have read and understand the above and attest that I am the parent or legal guardian of the child listed above and that I have the authority to authorize Indiana University of Pennsylvania to use their photograph/video(s) and name.

Guardian should type her/his full name below to authorize Photo Release *

First Name Last Name

ELECTRONIC SIGNATURE/CONSENT

Please read the following:

By typing my name below, I am electronically signing this application, and verifying that all information provided is accurate and true, and that I am legally responsible for the camper named in this application. My electronic signature indicates that I understand that my registration information will be shared with IUP's Office of Undergraduate Admissions for recruitment purposes and could include print, email, text and other communication in the future.

Please type your (the camper) name to electronically sign this application *

First Name Last Name

Guardian should type her/his full name below to electronically sign this application *

First Name Last Name