Back to School Camp Registration Form
Please fill out this form to register for the upcoming camp and have your details ready.
August 6th & 7th, 2026
Camp Held At: Shawnee Community College Main Campus 8364 Shawnee College Rd, Ullin, IL 62992
Student Information
Student's Full Name
*
First Name
Last Name
Student's Email
example@example.com
Student's Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent Information
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email
example@example.com
Emergency Contact Information
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Email
example@example.com
Emergency Contact Relationship
*
Medical Information (Optional but Recommended)
Allergies (food, medication, environmental):
Medical Conditions:
Medications (student will bring/administer):
Physician Name & Phone (optional):
Health Insurance Provider:
Policy #:
Authorization, Consent & Release
Assumption of Risk & Release of Liability
*
I acknowledge that participation in this trip may involve inherent risks associated with travel and activities. To the fullest extent permitted by law, I agree to release and hold harmless Educational Talent Search (TRIO), its sponsor institution, partner schools, employees, volunteers, and agents from any and all claims arising from my child’s participation, except in cases of gross negligence or willful misconduct.
Medical Treatment Authorization
*
In the event of an emergency and if I cannot be reached, I authorize Educational Talent Search staff and chaperones to secure medical treatment for my child as deemed necessary by licensed medical professionals. I accept responsibility for any medical expenses incurred.
Transportation Release
*
I authorize my child to be transported as indicated above and understand that transportation may be provided by school-approved vehicles and drivers.
Code of Conduct
*
I understand that failure to follow instructions or behavior expectations may result in my child being sent home at my expense.
Photo/Video/Media Release (Optional)
*
YES, I grant permission for photographs, video, or audio recordings of my child to be used for educational, informational, or promotional purposes related to Educational Talent Search, without compensation.
NO, I do not grant permission.
Parent Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Register
Register
Should be Empty: