2012 KIDS & TEEN COLLEGE
REGISTRATION FORM PAGE 3 REGISTRATION INFORMATION - Continued
STUDENT’S NAME (PLEASE BE SURE TO SIGN ON ALL LINES ASKING FOR A SIGNATURE)
University Releases I, the undersigned (parent/guardian) of________________________________, a minor, ask that s/he be admitted to participate in the youth program sponsored by The Pennsylvania State University.
In consideration of such admission
I do hereby agree to release, discharge, and hold harmless The Pennsylvania State University its officers, agents, and employees, of and from all causes, liabilities, damages, claims, or demands whatsoever, on account of any injury or accident involving the said minor out of the minor’s attendance at the program or in the course of competition and/or activities in connection with the program.
I/we authorize Penn State personnel to photograph, videotape and/or audiotape my/our child in promotion of Penn State’s Youth Programs.
(Please check one) _______ Yes _______ No
Additionally, I have reviewed the Behavior Expectations found on the General Information page of the camp website with my child, who agrees to follow these expectations. These expectations apply to all participants of youth programs at Penn State Abington.
Parent/Guardian signature______________________________________Date__________________________ COMPUTER ACCESS ACCOUNTS
(The following sections must be completed for all programs in which students will be using computer labs.)
Proof of Identity of a Minor The purpose of this form is to provide a means by which a parent or guardian can attest to the identity of a minor (an individual who is under 18 years old). In the event that the parent/guardian cannot accompany the minor, this form provides a way for Penn State to affirm the minor’s identity. The minor’s identity must be verified at the time he/she is issued a Penn State Short Term Access Account (STAA). The STAA is required for any programs that utilize the computer labs. This form will not be retained by Penn State. Once the minor’s identity is verified by Penn State Staff, this form will be shredded at the conclusion of the program.
Student Information First Name
Gender: Male Female Height: Feet Last Name Inches Hair Color
By signing this form, I affirm that the information shared on this form is true and correct.
Parent/Guardian Signature MI Age Eye Color
Parent/Guardian Information (This section must be completed by a parent/guardian if the student is under 18 years of age) Your Relationship to the Minor: Father
Mother Parent/Guardian Last Name Home Address: Street
Parent/Guardian Photo Identification Type: Driver’s License
ID Number Passport City Company ID ID Expiration NOTE: The Parent/Guardian will be required to show photo identification prior to or at the start of the program. Page 3 of 4 20 WWW.ABINGT
ON.PSU.EDU/YOUTHTEEN Guardian Parent/Guardian First Name State Other (Please specify) MI ZIP Date
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