Summer Innovation Lab

Nubian Directions II, Inc.

giuseppe@nubiandirections.org

www.nubiandirections.org

(845)-452-8574
Summer Innovation Lab

AGES 16 TO 19 ONLY | DATES ARE FROM JULY 1ST TO AUGUST 16TH
- Full Name
  
  First NameMiddle NameLast Name
- Birth Date
  
  MonthDayYear
- Email
- Phone Number
  Format: (000) 000-0000.

Permanent Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Emergency Contact

First NameLast Name
Relationship
ex. Father, Mother, etc.
Address Of Person To Contact In Case Of Emergency

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Phone Number Of Person To Contact In Case Of Emergency
Please enter a valid phone number.Format: (000) 000-0000.
Email Of Person To Contact In Case Of Emergency
example@example.com

CONTACT CONSENT: I consent to be contacted by Nubian Directions II, Inc. via phone, email, or any applicable method regarding this program.
NAME/PHOTOGRAPH RELEASE: Press organizations and Nubian Directions II, Inc. may do stories on the Summer Innovation Lab Workshops and/or activities and benefit the youth by showcasing their achievements. Please indicate whether or not you want your name or photograph to be released to the press.
DISCLAIMER: This camp is not regulated or inspected by the New York State Department of Health and is not required to obtain a Department of Health permit. This camp is not required to follow Department of Health regulations, including, maintaining minimum staff-to-child ratios; hiring medical personnel; or reporting injuries or illnesses to the Department of Health.
PARTICIPANT AGREEMENT: I agree to be an active participant in Summer Innovation Lab Workshops for the 2024 program. I will attend the activities and actively participate in project work. I will respect the presenters and the other participants in the program. I agree to attend all sessions or let program staff know in advance of a conflict. Sign name below.
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