Register for Marion 5-8 Grade Camp, June 19-23, 2017

Thank you for taking the time to register for the 2017 Jacobson Institute Entrepreneurship Camp. Campers will be at Hills Bank and Trust, 3204 7th Avenue, Marion, IA. Camp hours are from 8:30 a.m. - 3:00 p.m. every day the week of June 19-23, 2017.

Camp Cost: $225

Your payment will help cover the cost of week-long instruction, class materials, camp t-shirt, bus transportation for tours, snacks, and the graduation reception. In an effort to keep camp dues low and due to increased dietary restrictions, lunch will not be provided for the campers throughout the week. Students are required to bring lunch from home.

Registration is on a first-come, first-serve basis and requires either a full payment or a $50 deposit upon signup (the $50 deposit will be waived for those who qualify for scholarships).

A limited number of scholarships are available for those who qualify for the free or reduced lunch program. Please contact the Jacobson Institute directly at 319-335-2204 to learn more.

Once you have registered for the camp be on the lookout for an email from jacobson-institute@uiowa.edu with more information about camp details and payment. Camp registration closes on May 26, 2017. All payments are non-refundable after May 26, 2017. Cancellations will be handled on a case by case basis. $50 deposits are non-refundable.

If you have any questions please contact our team at 319-335-2204 or jacobson-institute@uiowa.edu.

Camper Information
First name
Preferred first name
(what you'd like to be called)
Last name
School name
School city
Grade in school for fall 2017
Anticipated high school graduation year
Date of Birth
Gender (optional) Male
Female
Race (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 a former camper was the referral, please give his/her name:


If other, please identify:
Did the camper previously participate in Invent Iowa? Yes
No
Medical Information (optional)
Please list any medical conditions you would like the camp staff to be aware of which may affect or be affected by the camper's participation
Current medications
Allergies
Does the camper have any dietary restrictions?
i.e., vegetarian, gluten free, food allergies, religious
Yes
No

If yes, please list:
Date of last tetanus immunization
Other information (i.e., behavioral concerns, etc.)
Name of physician
Physician phone number
Guardian(s) Information
Primary contact full name
Primary contact phone
Primary contact email
Secondary contact full name
Secondary contact phone
Secondary contact email
Emergency contact full name
Emergency contact phone
Emergency contact email
Preferred Address
(you will receive a letter with camp details and instructions in June)
City State Zip
Permission to Participate
By checking the box below I grant the camper permission to participate in the 2017 Jacobson Institute Entrepreneurship Camp in Marion, June 19-23, and agree to attend the graduation ceremony upon the camper's completion of the program.
I grant permission

Farmers Market
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 checking the box 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 understand

The farmers market will run from 4:00 - 7:00 p.m. on Thursday, June 22, and campers will be split into two different time slots.
Please select your preferred time slot

I would like my camper to attend the optional farmers market during the week of camp and prefer to have my child in the 4:00-5:30 time slot.

I would like my camper to attend the optional farmers market during the week of camp and prefer to have my child in the 5:30-7:00 time slot.

Waiver and Release

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 checking the box 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 to participate in the Jacobson Institute Entrepreneur Camp

  Parent/Guardian Electronic Signature

Media Release

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: I would like to pay the full $225 now.

Pay the $50 deposit: I would like to pay the $50 deposit now and pay the outstanding balance of $175 before registration closes on May 26.

Scholarship: I would like to apply for financial assistance because my camper qualifies for the free or reduced lunch program.
A limited number of scholarships are available for those who qualify for the free or reduced lunch program. If you do not qualify for the free or reduced lunch program, but are in need of a scholarship please select the "scholarship" option above and fill out the statement of need information.


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

John Pappajohn Entrepreneurial Center The University of Iowa