Student Information Form (no web advisor)

Student Information Form

Once this form is completed you will be able to move into the registration.
Student/Child Information
Student Name*

First NameMiddle Name (If no legal middle name, please enter 'x')Last Name
Grade completed as of June 2024*
Student Gender
School District*
Other School District
Birth Year*
Student Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County*
Other County

Parent/Guardian Information
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Phone*
Please include your area code and enter only numeric digits. Example 3197522731
Alternate Phone Number
Primary Email (For camp communication)*
example@example.com
Primary Phone Number (For camp communication)*
Please enter a valid phone number.

Emergency Contact
Emergency Contact Name*
Emergency Phone Number*
Please enter a valid phone number.
Relationship to Student*
Does your student have any food allergy, medical, physical or emotional conditions that require special accommodations or require medication on a regular basis? (If no, please type N/A below)*

Photo Agreement & T-Shirt
Photos taken during Kidtek U activities may be released to newspapers, posted on SCC bulletin boards, or released for other media and advertising purposes. Photos of my child may be used as stated above.*

YesNo
Photo release special instructions:
Student T-Shirt Size*

Disclaimer Statement
I the parent/guardian for the student information sheet warrant the truthfulness of the information provided in this application. I understand that signing this box constitutes a legal signature confirming that I acknowledge and agree to the above information.

For questions please call 319-208-5375.
Signature of person completing this form*

Clear
Relationship to the Student*
Should be Empty: