Fields marked with a * are required. Camper's Last Name * Camper's First Name * Camp Name * PRE-K: June 16-20: Bugs, Butterflies & Beasts, O my! PRE-K: July 7-11: “Sci-cation” CampK-5: June 16-20: Eureka! Experiment CampK-5: June 23-27: Backyard Bugs & BeastsK-5 MINICAMP: June 30-July 2 (Mini-Camp): Science Girls!K-5 MINICAMP: June 30-July 2 (Mini-Camp): Let’s Experiment!K-5: July 14-18: Summer “Sci-cation”K-5: August 11-15: Backyard Bugs & BeastsMIDDLE SCHOOL: August 4-8: Medical Research Camp at Virginia Tech Carilion Proof of income eligibility? (Check one ... upon acceptance, you will be asked to provide this documentation.) * Receive free or reduced price meals at school.Receive Supplemental Nutrition Assistance Program (SNAP) benefits.Receive Temporary Assistance for Needy Families (TANF) benefits.Foster children who are the legal responsibility of a welfare agency or court. Camper Gender * MaleFemale Camper T-shirt size * Youth SmallYouth MediumYouth LargeAdult SmallAdult MediumAdult Large Camper Birthday * Does your child have any allergies? * YesNo If yes, please provide a list of allergies. Does your child have any special needs, behavioral issues, or learning disabilities that we should be aware of? * YesNo If yes, please explain. Parent/Guardian First Name * Parent/Guardian Last Name * Address 1 * Address 2 City * State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampsire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code * Email * Cell Phone Day/Work Phone Parent/Guardian #2 First Name (if applicable) Parent/Guardian #2 Last Name (if applicable) Parent/Guardian #2 Address (if different) Email Cell Phone Day/Work Phone In case of emergency, which parent/guardian should we contact first? * Alternate person who would be authorized to assist your child if we cannot reach either parent in an emergency: Alternate person phone RELEASE & WAIVER: My child is physically fit and able to participate in camp activities. S/he may receive emergency care if needed. * My child has permission to participate in any camp field trip(s). Additional information will be sent to parents prior to trips. * RELEASE & WAIVER: Photographs or video recordings may be taken during camp for use in the Science Museum’s marketing materials. Identifying information will not be published. PLEASE CHECK HERE IF YOU DO NOT GIVE PERMISSION for your child’s image to be used in any or all media. (Declining does not prohibit your child from participating in any part of the camp program.) Upon submitting, you will receive a confirmation email that provides payment instructions. You may either mail a check or click a link to our online payment option. CLICK HERE FOR PAYMENT!