GenCyber Student Registration Application Form

Who: Students entering grades 9, 10

What: GenCyber Camps

When: July 18 – 22, 2019 (tentative) | 9:30 a.m. - 4:30 p.m.

Where: Inver Hills Community College

Cost: $0.00 - FREE

Fields marked with a (*) are required.

Student First Name:*
Student Last Name:*
Street Address:*
City, State, Zip:*	,
Phone:
Date of Birth:
Email:*
School:*
Grade entering in Fall 2018:*
Have you ever participated in the GenCyber MSP Camp at Inver Hills Community College? YesNo
Have you ever attended any GenCyber Camp in Minnesota? YesNo
Please note: previous attendance at Gen Cyber camps won't disqualify you from attending the Inver Hills Community College 2018 Gen Cyber camp. We will give priority acceptance to students who have not attended a Minnesota Gen Cyber camp. The 2nd priority will be those who have attended another Minnesota Gen Cyber camp (but not the IHCC camp).
Completion of This Section is Voluntary MaleFemale Ethnic Origin: The information requested is needed for reporting and research purposes. It will be kept confidential and will not be used as a basis for enrollment or in a discriminatory manner. The information collected will be used for summary reports required by federal and state laws and regulations to support institutional affirmative action. Summary reports do not identify individuals. Refusal to provide any of the requested information will not affect your enrollment. Students with disabilities are encouraged to contact the Supplemental Services Coordinator on campus to arrange appropriate support services.
Photograph and Video Consent Release I hereby give Minnesota State Colleges and Universities, and its successors and assignees, the right to use, reproduce and distribute photography and/or videography in which I appear for educational, publication or marketing purposes without any compesation to me. I understand that Minnesota State Colleges and Universities shall have total and exclusive control over the use of photography and videography in which I appear, and I waive any right to inspect or approve any proposed publication in any medium. I hereby release Minnesota State Colleges and Universities and its successors and assignees from any liability by virtue of my photograph and/or video. I state that I am at least 18 years of age and am competent to contract in my name. (If not at least 18, must have the signature of a parent or guardian.) * By checking the box, you, the student's parent or guardian, confirm that you have read and understand the above.
GenCyber Field Trip The student's parent or guardian * By checking the box, you, the student's parent or guardian, give permission for your child to participate in a field trip as a part of the 2018 GenCyber camp
Emergency Information Person to be called in case of an emergency Telephone Number List any medical or physical factors that should be known about this child: * In case of minor illness or injury, you, the student's parent or guardian, give your permission for the supervisor of your child to administer necessary treatment and/or first aid.
Parent/Guardian Name:*
Parent/Guardian Phone: *
Date:*