1 Cyber Defenders Summer Camp Application Form Instructions The Cyber Defenders Summer Camp is put on by the San Antonio College Computer Information Systems Department. It will be an overview of material covered in the Information Technology and Security Academy (ITSA) dual credit program and Cyber Security. A Texas Workforce Commission grant will provide Governor s Summer Merit Program scholarships for qualified participants valued over $240. *Students must be a student in a Texas middle or high school. A recent report card should be included with the application *Students must be ages 14 to 21 on the first day of camp. Birthdate documentation must be provided with application. Valid documents include: Baptismal record, Birth certificate, Driver s license, Passport *Original school and age documentation must be physically shown and copied by the CIS Department Nail Technical Center Room 229 on the San Antonio College campus prior to the first day of camp (preferably at the time of application). Call (210) with questions. Fax completed application to SAC CIS at (210) or Mail completed application to Troy Touchette CIS 1300 San Pedro San Antonio, TX or Hand deliver applications to Nail Technical Center Room 229 on the San Antonio College campus.
2 Cyber Defenders Summer Camp Application Form Student Information Last name First name Middle Gender M F Age Street address City State Zip code Name of your high/middle school* Phone # Date of birth* Ethnicity Hispanic Black (Non-Hispanic) White (Non-Hispanic) Asian/Pacific Islander Native American/Alaskan Native T-Shirt Size: Overall GPA is: Are you interested in a career in IT? Y N Are you a member of an IT-related student club at your school? Y N Are you a Texas foster youth? Y N Please list your top three career choices in the blanks below. Parent/Guardian Information Parent/guardian last name Parent/guardian first name Employer (if applicable) Primary phone # Secondary phone # Primary address Address (if different from what is listed above) Are you the student s emergency contact? Y N Which Cyber Defenders Summer Camp session would your child attend? Aug 4 th -8 th Aug 11 th -15 th If not, what is the name and phone number of the student s emergency contact? Would you require: Early drop off (between 7:30 a.m.-8:45 a.m.) Late pick up (between 4:15 p.m.-5:30 p.m.)
3 Cyber Defenders Summer Camp Application Form Student Essay: In no more than 500 words, tell us why you want to attend the Cyber Defenders Summer Camp and how it will help you achieve your future education and career goals.
4 Cyber Defenders Summer Camp Emergency Form PARENT/GUARDIAN S PERMISSION Student s name: Date of birth: In case of emergency or if San Antonio College must contact me for any reason, I can be reached at (phone #) to be advised of where to pick up my child. If I cannot be reached, please contact (name) at (phone #). If neither party can be reached to make plans for emergency medical care for my child at the time of illness or accident, I give permission for San Antonio College staff to take my child to: Physician name: or Hospital name: Physician phone #: Hospital phone #: Insurance company: Policy number: Please list any of the student s known allergies or significant medical history: Parent/guardian signature: Date:
5 Texas Tort Claims Act TO THE PARENTS OR GUARDIANS OF CAMP PARTICIPANTS: San Antonio College (SAC) is pleased to be able to provide youth in the community with challenging, creative, safe and fun activities during the summer. We strive to make their time with us not only enjoyable, but safe. As parents and guardians of these children, we feel you should be fully informed of the conditions under which your children are visiting our campuses. Under the Texas Tort Claims Act, SAC and the Alamo Community College District are a political subdivision of the State of Texas. Under this Act, the college district is not responsible or liable to any person for property damage, personal injury or death. The only exception to this involves a college district-owned vehicle. Under the Act, the damages the college district may be held responsible for are limited for property damage, personal injury or death caused by a college district-owned vehicle. The Cyber Defenders Summer Camp could include field trips to information technology employers or other college and university campuses. As with the school districts your child attends during the school year, SAC and the Alamo Community College District require a Release and Indemnification Agreement from the parent and guardian of each child. The attached Release and Indemnification Agreement is mandatory for your child s participation in the Cyber Defenders Summer Camp. It gives your permission for your child to participate in any field trips that may take place and to be transported on those trips by college district vehicles and personnel. Signed Releases must be returned prior to the start of the program to allow your child s participation. Please be assured that every effort has been made to provide your child with a healthy, safe environment in which to enjoy this summer program. Should you have any questions, please call the SAC Computer Information Systems (CIS) Department at
6 Release and Indemnification Agreement Form Release and Indemnification Agreement concerning: Student s name: The undersigned representative, on behalf of the child named above (hereinafter the child ), who desires to participate in the Cyber Defenders Summer Camp activity, and in consideration of being permitted to participate in said activity, voluntarily and knowingly executes this release and indemnity agreement on behalf of the child with the express intention of extinguishing the rights and obligations designated herein. Permission is also provided for the child to participate in field trips off campus and for transportation by District personnel and vehicles. As representative of the child, I hereby elect to and assume all risks for claims hereinafter arising, known or unknown, from the conduct of the Kids Camp activity and hereby knowingly and voluntarily expressly release the Alamo Community College District, its employees, agents, representatives, officers, directors or others acting on behalf of Alamo Community College District, from all liability for claims arising out of such matters. With the intention of binding the child and with full authority to do so, I hereby release, discharge and indemnify the Alamo Community College District, its employees, agents, representatives, officers, directors or other acting on behalf of Alamo Community College District, from any and all claims, demands, actions, judgments and executions which the child ever had, or now has, or ever will have, or which the child may claim to have against Alamo Community College District, its employees, agents, representatives, officers, directors or others acting on behalf of the Alamo Community College District, in connection with or arising out of, directly or indirectly, any and all matters relating to the Kids Camp activity, including any alleged acts or negligence by the District s employees, agents, representatives, officers, directors or others acting on behalf of the Alamo Community College District. As the duly authorized agent of the child, I have read this release and indemnification and understand all of its terms. This release and indemnification agreement is executed voluntarily and with full knowledge of its contents and significance. Signature of duly authorized representative for child: Printed name: Date:
7 Acknowledgement of Drop Off and Pick Up Policy I have read and understand the policy and location for dropping off and picking up my child. I understand that San Antonio College and the Computer Information Systems Department cannot be held responsible for my child if she/he is dropped off before 7:30 am. After 5:30 p.m., any child not picked up will be escorted to the SAC D403 Annex, where the parent will pick them up. I understand that it is my responsibility to know what classroom my child is in and where she/he should be dropped off and picked up. I understand the drop-off and pick up times to be the following: 7:30 a.m. Early Drop off 8:45 a.m. Regular Drop off By 4:15 p.m. Regular Pick up By 5:30 p.m. Late Pick up Student s name: Parent/guardian s primary contact number: Parent/guardian s alternate contact number: I DO DO NOT give permission for my child to leave the San Antonio College campus unescorted to either walk home or take public transportation at p.m. Parent/guardian signature: Date: IF YOU HAVE NOT PICKED UP YOUR CHILD BY 5:30 P.M., PLEASE CALL THE SAC COMPUTER INFORMATION SYSTEMS DEPARTMENT AT IMMEDIATELY.
8 Photo/Media Release Form RIGHT OF CONSENT RELEASE WITHOUT COMPENSATION: Individual Consent Form Project Working Title: SAC CIS Cyber Defenders Summer Camp/Summer Merit Program Production Location: San Antonio College Production Date(s): August 2014 Instructor/Dept.: Computer Information Systems I understand that the project mentioned above is being produced and distributed by the Alamo Colleges (referred to as Colleges in this agreement). I also understand that by this release I consent to the use of my likeness and voice, including all related photographs and/or sound recordings, for research, educational, and advertising purposes by the individuals authorized by the Colleges. I also acknowledge that the Alamo Colleges is and will be the sole owner of all rights to such video, photographs, and/or sound recordings of my participation, and I shall not receive compensation for my appearance and voluntary participation in this project. / Signature of participant/ Date If not over 18: I represent that I am the parent/guardian of the above named person. I hereby consent to the foregoing on his/her behalf. / Signature of parent/guardian Date
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