Please complete this registration form or fill out the print form and fax to Sharon King at (601) 266-6075. You may also submit payment and registration through mail to the address listed at the end of the application. Once we receive it, we will send you specific information about the program, including directions to the Eagle Maker Hub.
One-Day camps are on Thursdays from 9am to 3pm. Two-day camps are Monday and Tuesday from 9am to 3pm. Bring your own sack lunch for each camp day.
Please select the camps you would like to attend.
June 11-12: Superhero Maker Camp. Make your own superhero stuff! Design your own tee-shirt, mask, and whatever else you would like to 3D print or create! Cost $125.00. Cost includes all materials. Grades 4-6.June 14: Rube Goldberg Machine. You've seen those videos where you start with a marble that goes through a series of things that move... build your own Rube Goldberg Machine in this camp! Cost $75.00. Cost includes materials for the day. Grades 7-10.June 18-19: Beginner Arduino. Coding lights, sounds, and robotic actions. Cost $170.00. Cost incudes Arduino kit. Grades 7-10.June 21: Mini-Robots. Learn to code and work with robots. Make and take your own mini-robot home! Cost $75.00. Cost includes materials for the day. Grades 4-6.
Shirt Size: YSYMYLASAMALAXLAXXLAXXXL
Method of Payment: CashCheck
Make check out to Eagle Maker Hub. Please list name of camp on check or mailed application.
Date of Birth (mm/dd/yyyy):
Presently enrolled at
Grade in Fall 2018: 3rd4th5th6th7th8th9th10th
Parent(s) or Guardian(s) Name:
Phone Numbers (provide at least one):
In case of emergency, contact: FatherMotherGuardian
For your child to receive medical care in the event of illness or injury while participating in the USM event, we ask that you bring a copy of all relevant insurance information for your child with you to the event. We will store it securely until the end of the program, where we will then return the copy to you.
Is it permissible to provide medical treatment for your child if needed? YesNo
Please state any special medical conditions that may require staff attention:
Does your child take medication on a regular basis of which we need to be aware? YesNo
If yes, please explain:
Does your child have any known allergies? YesNo
Is your child under the care of a psychologist/psychiatrist, or being treated for any emotional or mental issues? YesNo
Are there any restrictions of physical activity that may apply to your child? YesNo
Yes, I grant permission for my child to be photographed or videotaped during this event. This includes photos that may be used for promotional or publicity purposes.
Yes, I would like to receive information about other events through the Eagle Maker Hub at USM.
I certify that my child has permission to attend the Eagle Maker Hub Camp event at USM's Eagle Maker Hub.
I release USM from any and every liability, claim, right of action of any kind or nature which my child or legal representative may have for any and all bodily or personal injuries or property damages or any other damages resulting there from which might occur during participation in this program and host institution(s), or representative(s) thereof, and the management or owner(s) of any physical facility in which the program is conducted.
Parent or Legal Guardian's Name:
Parent or Legal Guardian's Signature (Type in signature.):
Date signed (mm/dd/yyyy):
The parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.
Send payment to:
Eagle Maker Hub
Univ. of Southern Mississippi
118 College Drive #5018
Hattiesburg, MS 39406-0001