Data Science Summer Institute Registration Form

First Name*

Last Name*

Gender*

Male

Female

I prefer not to say

Hidden

Which most accurately describe(s) you?

Choose as many as you like

Woman

Man

Non-binary

Let me type...

I prefer not to say

Hidden

I describe myself as:

Address*

City*

State*

Zip Code*

Phone

Cell*

Email Address*

Date of Birth

Age*

T-shirt size (adult)*

Grade in September*

9th

10th

11th

12th

Emergency Contact Information

Must be a parent or guardian if under 18.

First Name*

Last Name*

Relationship*

Address*

Same as above

Different

Address*

City*

State*

Zip Code*

Phone

Phone 2

Cell Phone*

Please provide the following in the event the primary contact cannot be reached.

First Name*

Last Name*

Relationship*

Cell Phone*

Phone

List any other information that you think would be valuable for Camden County College staff to be aware of that would make your day with us more enjoyable for you:

Release of Liability Signature*

Parent/Legal Guardian for Participant under age 18

Date*

Photo Release Signature*

Parent/Legal Guardian for Participant under age 18

Date*

Participant Signature*

The undersigned consents to participate in any and all activities

Date*

Parent/Legal Guardian Signature*

The undersigned gives permission for the Participant to participate in any and all activities. Parent/Legal Guardian for Participant under age 18

Date*

Name

This field is for validation purposes and should be left unchanged.

Camden County College

Academics

Admissions & Financial Aid

Student Life

Workforce Training & Continuing Education

Data Science Summer Institute Registration Form

Emergency Contact Information