OHIO STATE UNIVERSITY EXTENSION

When: June 6-8, 2017 Time: 9:00 AM to 11:30 AM, daily Where: Global Impact STEM Academy (GISA) 700 S. Limestone Street, Springfield Who: 4th-7th grade youth - limited to 100 Cost: $45 includes t-shirt, snacks, all activities. Registration Deadline: May 25 or until full. Complete the registration form on the back. Questions: Call 937-521-3860 or e-mail house.18@osu.edu

cience comes alive as you become Food & Polymer Scientists in the GISA Lab along side student

mentors from GISA. Make bio-based bubbles, fruit caviar, gourmet flavored popcorn, ice cream & more.

echnology used by health professionals and fitness experts will allow you to assemble your own

fitness tracker. Collect and analyze fitness data, take home your tracker for continued use and discovery.

ngineering innovation has great rewards when you work on a team to design and construct

a hammock that will hold one of your team members.

ath will mean more when you create an iMovie to market your STEM-tomic creations to the GISA team.

FUN Learning

and STEM

Discovery

OHIO STATE UNIVERSITY EXTENSION

Name: _______________________________________________________________________

Gender: Male Female Age: _________

Grade (fall 2017): 4th 5th 6th 7th

T-shirt Size Adult Sizes: S M L XL 2X

Address: ______________________________________________________________________

City/State/Zip: _________________________________________________________________

Parent/Guardian Name: __________________________________________________________

Relationship: ___________________________________________________________________

Home Phone: _________________________ Cell/Work Phone: _________________________

E-Mail: _______________________________________________________________________

Allergies: _____________________________________________________________________

List any pertinent medical/health concerns: ___________________________________________

______________________________________________________________________________

Special Accommodations Needed: _________________________________________________

______________________________________________________________________________

Name and Phone Number of Emergency Contact During Event: __________________________

_____________________________________________________________________________

Photo and Video Release: I give I don’t give Ohio State, GISA, Clark Co. 4-H permission to publish in print, electronic or video format the likeness or image of my child. I release all claims against these organizations with respect to copyright ownership & publication including any claim for compensation related to use of the materials.

__________________________ _________________________ ___________________ Participant’s Printed Name Participant’s Signature Date

__________________________ _________________________ _________________ Parent/Guardian Printed Name Parent/Guardian Signature Date

Complete Form and Mail with Payment to Clark Co. 4-H, P.O. Box 444, Springfield, OH 45501

OR Fax Registration to: 937-328-4609 and Mail Payment to address above

Registration Deadline:

May 25 or Until

Camp is Full