Register for Iowa City 5-6 Grade Camp, June 18-22, 2018

Location: Kirkwood Regional Center @ The University of Iowa, 2301 Oakdale Blvd, Coralville, IA
Grades: 5 - 6 grade students
Camp Hours: 8:30 a.m. - 3:00 p.m. every day + farmers market the night of Wednesday, June 20
Extended hours are available at this location from 7:45 a.m. - 5:30 p.m. for an additional $50.

Camp Cost: registration is on a first-come, first-serve basis
$200 Feb. 1 - Mar. 21, 2018 (with full payment)
$250 Mar. 22 - May 25, 2018
$50 extended hours option available at this location
*A limited number of scholarships are available. $50 deposits are non-refundable. ALL payments are non-refundable after May 25, 2018. Cancellations will be handled on a case by case basis.

Your payment will help cover the cost of instruction, materials, t-shirt, bus transportation, daily snacks, and a graduation reception. Students are required to bring lunch from home throughout the week. *Pizza will be provided for campers during lunch on Friday. Please plan accordingly.

Camper Information (required)
First name
Last name
School name
School city
School state (XX)
What grade will the camper be going into this fall 2018?
Anticipated high school graduation year (yyyy)
Date of Birth (mm/dd/yyyy)
Gender (optional) Male
Female
Race/Ethnicity (optional) White
Hispanic or Latino
Black or African American
Native American or American Indian
Asian/Pacific Islander
Other
What size T-shirt will the camper wear this summer?
How did the camper learn about this camp?

If other, please identify:
Medical Information (optional)
Please list any medical conditions or behavioral concerns you would like the camp staff to be aware of which may affect or be affected by the camper's participation.
Please list any medications you would like the camp staff to help administer during camp. Please include medication instructions.
Please list any severe allergies or dietary restrictions that may affect your campers experience at camp (i.e. vegetarian, gluten free, food allergies, religious, etc.).
Name of physician
Physician phone number
Parent/Guardian(s) Information (required)
Primary contact full name
Primary contact phone
Primary contact email
Secondary contact full name (optional)
Secondary contact phone (optional)
Secondary contact email (optional)
Emergency contact full name
Emergency contact phone
Emergency contact email
Preferred Address
(you will receive a letter with camp details in June)
Street
City
State (XX) Zip
Permission to Participate (required)

By filling in the bubble below I grant the camper permission to participate in the 2018 Jacobson Institute Entrepreneurship Camp in the Iowa City area, June 18-22, and agree to attend the graduation ceremony upon the camper's completion of the program.

I grant permission.

Farmers Market (required)
During camp, each participant will create products and have the opportunity to sell them at the farmers market. Tables will be set up for all of the campers to be together! By filling in the bubble below I understand that I will be providing transportation to and from the event. I also understand my camper will be responsible for all materials needed to run their business at the market (i.e. money to make change for customers).

I understand.
The farmers market will run from 5:00 - 7:00 p.m. on Wednesday, June 20, at the Iowa City Farmers Market in the Chauncey Swan Ramp and campers will be split into two different time slots.
Please select your preferred time slot:

I would like my camper to attend the farmers market during the week of camp and prefer to have my child in the 5:00-6:00 time slot. Please note: If your camper is enrolled in extended hours and chooses this option you as the parent/guardian will still be required to provide transportation to the farmers market.

I would like my camper to attend the farmers market during the week of camp and prefer to have my child in the 6:00-7:00 time slot.

Extended Hours (required)

I would like to register my camper for the extended hours program from 7:45 a.m. - 5:30 p.m. Monday - Thursday during the week of camp. I understand that this program is an additional $50 and that the payment will be collected at a later date if I do not pay for the camp in full today. I also understand that extended hours will be available Friday morning, but not available Friday afternoon due to the graduation ceremony and end of camp. In the case of limited enrollment, the extended hours program may be cancelled and you will be contacted.

Yes
No
Waiver and Release (required)

In consideration for The University of Iowa granting my son/daughter permission to participate in the Jacobson Institute Entrepreneur Camp, I hereby assume all risks of property loss and damage and personal injury, including death, which may result from my child's participation in any Jacobson Institute Entrepreneurship Camp activity. I do hereby release The University of Iowa; Board of Regents, State of Iowa; the State of Iowa and their employees, agents and representatives from any and all liability associated with my son's/daughter's participation, except to the extent that such liability is a direct result of The University of Iowa's negligent acts or omissions. I understand and appreciate the inherent risks of participating in the Jacobson Institute Entrepreneurial Camp activities. I know the risks may include, but are not limited to physical injury, including without limitation, scrapes, bruises, strains, sprains, exacerbation of medical conditions, and loss or damage of personal property. I fully assume the inherent risks associated with attending a program at The University of Iowa and assert that my child has chosen to participate in this program, with my express approval.

By filling in the bubble below, providing my electronic signature, and submitting this registration form I certify that: I am the parent or legal guardian of the participant named on this form; I have read this release of liability, fully understand it, freely and voluntarily sign it, and am acting for myself, my child, my heirs, personal representatives and assigns in doing so.

I understand and agree to the above terms and I am granting permission for my son/daughter/camper to participate in the Jacobson Institute Entrepreneur Camp.

  Parent/Guardian Electronic Signature

Media Release (required)

By checking the box below, I hereby consent to allow for my child to be photographed and his/her image and/or voice to be recorded. I hereby grant to The University of Iowa the rights to use my child's image, voice, name and/or likeness in any medium whatsoever for the purpose of promoting The University of Iowa or any of its units without any payment to me. I hereby expressly waive any rights of action I may have and release the State of Iowa; Board of Regents, State of Iowa; The University of Iowa, and their employees and agents from any and all liability arising out of or in connection with the use of such image, voice, name and/or likeness, including, but not limited to, any claims for any violation of any personal or proprietary right.The University, its successors and assigns shall own all right, title and interest, including without limitation the copyright of any such photograph, video-recording, and/or audio-recording.

Select one of the following:
I grant media permission
I do not grant media permission

Payment Options (required)
Please select which type of payment you will make today: Pay in Full: $200 Feb. 1 - Mar. 21, 2018 (with full payment); $250 Mar. 22 - May 25, 2018

Pay the $50 deposit: I understand that by selecting this option I am ineligible for the early bird discounted rate. I would like to pay the $50 deposit now and pay the outstanding balance of $200 before registration closes on May 25, 2018.

Scholarship: I would like to apply for a scholarship because my camper qualifies for the free or reduced lunch program or because my family is in need of financial assistance.
A limited number of scholarships are available.


Important communications will come from jacobson-institute@uiowa.edu.
Once registered: automated email with camp confirmation.
Last week in May: email with camp details.
First week in June: letter in the mail with camp details.
Week before camp: email with reminders for camp.

Please check that all of the information provided above is accurate. To complete your camp registration, select the "submit" button below and finalize camp payment on the next page.

John Pappajohn Entrepreneurial Center The University of Iowa