Rural Up Summer 2024 Camp Registration Form

Rural Up Summer 2024 Camps!

Offering 2 Camps This Summer for Rising 5th - 8th Graders: Mobile STEM Explorer Lab Camp & Cyber Arcade Camp with Micro:bit
Which Camp(s) Are You Signing Up For?

Each Camp has a $30 Registration Fee, which covers the week-long program, as well as snacks and drinks. Scholarship waivers are available. Additionally, for those enrolling in both the STEM Explorer Camp and the Cyber Arcade Camp, the combined Registration Fee is discounted to $50.
June 24-28 London's Children's Museum (Laurel County), M-F 9am-12pm dailyJuly 1-3 Jackson County Public Library in McKee (Jackson County) M-W 10am-3pm daily (*Registration fee is waived for ALL students who register)ANY REGISTRATIONS ARE NOW ON A WAITLIST FOR HARLAN CAMP-July 8-12 Harlan Independent High School (Harlan County), M-F 9am-12pm dailyJuly 15-18 Southeast Kentucky Community and Technical College (Knox County), M-Th 10am-3pm daily (*Registration fee is waived for ALL Partners for Rural Impact students*)July 22-26 EKU Manchester Campus (Clay County), M-F 9am-12pm daily
June 24-28 London's Children's Museum (Laurel County), M-F 1pm-4pm dailyJuly 8-12 Harlan Independent High School (Harlan County), M-F 1pm-4pm dailyJuly 22-26 EKU Manchester Campus (Clay County), M-F 1pm-4pm daily
Camper's Basic Details

By filling out the form below, you are confirming that you are the participant's parent or legal guardian. You must be the parent or legal guardian to register someone under 18 years old.
Camper Name:

First NameLast Name
Camper's Preferred Name:
Camper's Date of Birth:

MonthDayYear
Date
MaleFemalePrefer Not to Say
Residential County:
School Camper will Attend this Fall:
Camper will be attending which grade this fall:
Does the student have any food allergies or dietary restrictions? Does the student have any special accomodations?
Why are you and/or the student interested in this/these program(s)?
What has the student created recently that they are proud of (does not have to be STEM related, can be anything!)
Emergency Contact Information

Please enter the name of the parent or guardian who should be contacted in the case of an emergency.
Full Name

First NameLast Name
Contact Phone Number
Please share a cell phone number. By sharing a number here, I authorize Rural Up, Inc. to send text messages in regards to the summer camps as a way to provide information in a timely manner. Your inforamtion will not be sold, distributed, or in any other way shared outside of Rural Up, Inc.Format: (000) 000-0000.
E-mail
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Publicity Release

I grant Rural Up, its representatives, and employees the right to take photographs, videos, use statements or biographical information of my student pertaining to Rural Up services. I authorize Rural Up, its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that Rural Up may use such photographs of my student with or without their name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and web content. We waive our right to inspect or approve the finished products. I also agree that I, nor my student, will not be compensated for the use of my name, photograph, videos, or biographical information. I hereby release Rural Up from all and any liability arising out of the exercise of the rights granted in this release.
Signature (Publicity Release)
Signature Date

MonthDayYear
Date
Liability and Procedural Agreement

I hereby release, hold harmless, defend and indemnify Rural Up, Inc. from any and all damages, injuries and causes of action which may accrue to or be asserted by me or any minor child of mine arising directly or indirectly from my participation or my minor child's participation in Week of Code with Rural Up, Inc.
Participant or Parent Signature (Liability and Procedural Agreements)
Signature Date

MonthDayYear
Date
Instructions for Payment

To confirm your student's participation, kindly complete your registration fee payment via our webpage at www.ruralup.org/camppayment or by mailing a check to: Rural Up, Inc., P.O. Box 404, London, KY 40743. The deadline for payment submission is June 15th. If the registration fee poses a financial challenge, please reach out to us at info@ruralup.org to request a scholarship. We're committed to serving all students in the region. Thank you!
Any questions or concern:
Should be Empty:

Rural Up Summer 2024 Camps!

Which Camp(s) Are You Signing Up For?

Camper's Basic Details

Publicity Release

Liability and Procedural Agreement

Instructions for Payment