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I, the undersigned, as a parent or guardian of ________________________________, a minor, ask that he/she be admitted to participate in the Summer Youth Program sponsored by the Pennsylvania State University. In consideration of such admission, I do hereby agree to release, discharge, and hold harmless The Pennsylvania State University, its officers, agents, and employees of and from all causes, liabilities, damages, claims, or demands whatsoever on account of any injury or accident involving the said minor arising out of the minor's attendance at the Summer Youth Program or in the course of activities held in connection with the Summer Youth Program.

I authorize Penn State to photograph, videotape, and/or audiotape my child in promotion of the University or the Summer Youth Program.

My child and I understand that all University regulations must be followed. In addition, I have reviewed the Program Rules with my child, who agrees to follow these rules. You may also request to have the rules and regulations mailed to you or you may pick up a copy on the first day of the program.

I have also completed the Medical Treatment Authorization form and will submit that with this permission form to the University.

Agreed to by:
Parent's/Legal Guardian's Signature ____________________________________

Parent's/Legal Guardian's Printed Name _________________________________

Child's Name:_____________________________ Child's Date of Birth ________________________________

Address:___________________________________ City:__________________ State:_______ Zip:___________

Mother/Guardian's Home Phone:____________________ Mother/Guardian's Work Phone:__________________

Father/Guardian's Home Phone:____________________ Father/Guardian's Work Phone:__________________

Parent/Legal Guardian's E-mail Address:__________________________________________________________

Please check one:

Lunches may be available for the 2015 Summer Youth Program. Lunches are not available for the 2014 Summer Camps, unless specifically stated.

_______My child will need a lunch provided for him/her and will remain at Penn State Fayette over the lunch hour.
_______My child will not need a lunch but will remain at Penn State Fayette for the lunch hour.
_______My child will not stay at Penn State Fayette over the lunch hour. No lunch is needed.

Course fee: see course description for fees. Date Registered:_______________ 

Course or Camp Title (s):___________________________________________________________________________________




For more information, please contact Outreach & Continuing Education
Call: 724-430-4211
Fax: 724-430-4208
Web: fayette.psu.edu

Federal law requires that institutions of higher education gather the following information regarding the ethnicity and race of its students and employees. Your individual information will be kept strictly confidential. The law only requires institutions to report aggregate totals for each category. Select the appropriate responses regarding your ethnicity and your race:

  1. Is your ethnicity Hispanic/Latino (Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin)?
    _____Yes, Hispanic/Latino
    _____No, not Hispanic/Latino
  2. What is your race? (Select one or more)
    _____Black or African American
    _____American Indian or Alaska Native
    _____Native Hawaiian or Other Pacific Islander

Enclosed is my check for $________ made payable to: Penn State University

Charge my:
_____________________Card Number
_____________________Expiration Date

Mail to: Penn State Fayette, The Eberly Campus, Continuing Education, 2201 University Drive, Lemont Furnace, PA 15456.