REGISTRATION   FORM
(copy if necessary)
2019 Summer  Science Camp
June 24- 28 • 12:45 - 3:45 PM

Camper's Name

D Male	D Female

SchOol	GradeInFall'19

Parent/Guardian

Address

City	State	Zip

Home Phone

Cellor Wor1<Phone

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Parent/GuardianEmail

T-shlrt Size:	0YOUTH Small	0YOUTH Medium
0 YOUTH Large 	0 ADULT Small	0 ADULTMedium
0 ADULT Large 	0 ADULTHarge

PAYMENT: D Check	D MoneyOrder  en<losed
(payable to LourdesUniversity)

AUTHORIZATION:
You have mypermissionto take phOtographs ofmy child dur1ng summer workshOpactlvtlles for publldtyreasons.

R\ TT LOURDES
U NIVER S I TY

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Signature

Please detachandmall or bringto:

Spomoll'd by thr Sinm of St. Fnmris

Center for Science Education & the Environment
Department of Chemistry & Physical Sciences

June 24-28 • 12:45-3:45 PM

Center for Science Education & the Environment

LourdesUniversity 2019Summer S<lenceCamp
HolllBone,6832 Convent Blvd.,Sylvania,OH43

.) 	Space is Limited

Department of Education

6832 Convent Boulevard,Sylvania,Ohio 43560
Phone:419-824-3909
E-mail:hbone@lourdes.edu

Department ofChemistry & PhysicalSciences
Department ofEducation
419-824-3909

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2019 Summer Science Camp

MEDICAL  RELEASE FORM
Please fill this form out completely.
A medical release formforeaCh P<Jrtici pa nt must be on record with
theSdence Department before he/she may begin camp.

Physldan's Name

Physldan's Phone Number

June 24- 28 • 12:45- 3:45 PM Daily	ta'((\	 	

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Preferred Hospital

Please list any allergies,asthma or other health conmns

AlternateContact  Person

Phone

Insurance Information

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QUESTIONS? Contact Holli Bo ne at
419-824-3909 or
hbone@lourdes.edu

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Insured's Name

Carrier Name Carrier Address Certlficate/1D #
Group#

1authonze Lourdesstan to request medical treatment If
--- unable to reach parenV9uardlan.

Parent/GuardianSignature

Date