Clone of Artemis Camp 2025 Registration Form

Artemis Camp Registration

Artemis Camp is for ages 12-16. The camp best fits children who have completed sixth through tenth grade. Artemis Camp is only offered one week June 15-19. Please complete the entire registration .
Number of Campers Registering*
Select the week you wish your camper to attend.
Artemis Camp
Camper 1 Information
Camper 1 Name*

First NameLast Name
Camper 1 T-Shirt Size*
Birth Date

MonthDayYear
Grade*
Gender

MaleFemaleDecline to answer
Ethnicity:

American IndianAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or other Pacific IslanderWhiteBiracialDecline to answer
Camper 1 Lunch Option: Campers will be able to order a snack and lunch from the INFINITY Café on Friday. ($15 per camper)

3 chicken tenders with chips, cookie, drink and Italian Ice tube snack2 slices cheese pizza with chips, cookie, drink and Italian Ice tube snack2 slices pepperoni pizza with chips, cookie, drink and Italian Ice tube snackWill bring own lunch and snack
Camper 2 Information
Camper 2 Name

First NameLast Name
Camper 2 T-Shirt Size
Camper 2 Birth Date

MonthDayYear
Grade
Gender

MaleFemaleDecline to answer
Ethnicity:

American IndianAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or other Pacific IslanderWhiteBiracialDecline to answer
Camper 2 Lunch Option: Campers will be able to order a snack and lunch from the INFINITY Café on Friday. ($15 per camper)

3 chicken tenders with chips, cookie, drink and Italian Ice tube snack2 slices cheese pizza with chips, cookie, drink and Italian Ice tube snack2 slices pepperoni pizza with chips, cookie, drink and Italian Ice tube snackWill bring own lunch and snack
Parent/Guardian Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Contact Phone Number*
Work Number
E-mail*
example@example.com
Emergency Information
#1 Emergency Contact's Name*

First NameLast Name
Relationship
Phone Number*
#2 Emergency Contact's Name*

First NameLast Name
Relationship
Phone Number*
List of names, relationships and contact information for those approved to pick up camper.
List of names of campers you wish your child to be in the same group with. We will do our best to honor your request. We try to keep our groups within the same number of students and age groups based on the numbers registered. ( ages 7-8, 9-11.)
Medical Release and Authorization

As Parent and/or Guardian of the named camper, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to the INFINITY Science Center. and its affiliates including Directors, Camp Lead Teachers, and Counselors to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered season.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.
Does Camper have any allergies, chronic illness, or medical conditions?

YesNo
If yes, please describe.
Is the camper prescribed an inhaler or an EpiPen?

YesNo
If yes, please explain any instructions.
Medical Insurance Provider
Policy Number
Primary Physician:
Phone Number
Please enter a valid phone number.
My child(ren) may be photographed by INFINITY Science Center: Camper 1*
Camper 2
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Signature
Date

MonthDayYear
Date
NASA Media Release for Parent and Minor

I, {name}, am the parent /guardian /legal representative of {camper15} and do hereby give permission for the above-named minor child (hereinafter "Minor) to be interviewed, photographed and/ or videotaped by NASA or its representatives. I understand and agree that the text, photographs, and or videotapes containing the words,image and or voice of the inor may be used in the (hereinafter the "Program") and that such materials may be distributed or broadcast to the public and displayed publicly. I also understand that my permission to use the text, photographs and videotapes is for an unlimited duration and that neither I nor the Minor will receive any compensation for granting this permission or for the use, if any, by NASA of the Minor's words, image and or voice.

I acknowledge that NASA has no obligation to use the Minor's words, image or voice in connection with the Program.

I hearby unconditionally release NASA and its representatives from any and all claims and demands arising out of the activities authorized under the terms of this agreement.

By signing below, I represent that I am at least 18 years of age and am the parent/guardian/leagl representative of the above -named Minor. I have read the foregoing agreement and am familiar with all of the terms and conditions thereof and consent to its execution by the Minor. I agree that niether I nor the Minor will revoke or disafirm the this agreement at any time.
My child MAY NOT BE interviewed, photographed and/ or videotaped by NASA or its representatives.
Signature of Parent/Guardian/Legal Representative of Minor:*
Signature of Minor*
Date*

MonthDayYear
Date
Name and Location of Event:

INFINITY Science Center Summer Camp Program: Astro Camp and/or Artemis Camp

Address: 1 Discovery Circle, Pearlington, MS 39572

Telephone: 228-533-9025

Email: summercamp.isc@gmail.com

My Products

Artemis Camp June 15-19

$315.00 Quantity

Café Lunch and Snack Add-on

$15.00 Quantity

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Total

$0.00

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Artemis Camp Registration

Select the week you wish your camper to attend.

Camper 1 Information

Camper 2 Information