A week-long summer youth program of STEM-related aviation and space learning experiences!

Application
Deadline: April 22, 2011

June 20th to June 25th from 9:00 a.m. to 3:30 p.m. Monday – Saturday

Florida State College at Jacksonville’s Aviation Center of Excellence

Student Name: Parent/Guardian Name:

Address: Email:

Home Phone: Work Phone: Cell Phone:

Emergency
Contact: Phone:

School: Grade Entering This Fall:

Release Information

ACKNOWLEDGEMENT AND ASSUMPTION OF RISK: The undersigned acknowledges that the activity may involve risks and the undersigned
assumes the risk of any and all bodily injury and all property loss or damage arising in any way from said activity. The undersigned agrees
that Florida State College at Jacksonville (FSCJ) is not in any way a guarantor of safety in connection with the activity.

RELEASE: The undersigned agrees to release, indemnify, and hold FSCJ harmless from any such suits, actions, or claims which may be
asserted except those claims wherein FSCJ is determined to be at fault through its wrongful act(s) or omission(s).

INSURANCE: The undersigned is not relying on FSCJ for any manner of insurance for protection in connection with this activity. The
undersigned shall be responsible for providing all insurance to be relied upon for protection in connection with this activity and the
undersigned shall not hold FSCJ responsible for proving any insurance coverage.

PHOTOGRAPHY RELEASE: I hereby give my consent to all written materials, photographs, audio and/or video recordings taken of me or my
child during the activity. I understand that any such photographs, audio, video recordings or their derivatives will become the property of
FSCJ and may be used by the college or others with their consent for educational, instructional, or promotional purposes determined by the
college in formats now existing or in the future created.

______________________________________________________________________________________________________________
Parent/Legal Guardian Signature Date

13450 Lake Fretwell Street, Jacksonville, FL 32221 1

 Participant’s Letter of Application
Include a paragraph for each of the following questions

Why do you want to attend the Aerospace Adventures Summer Youth Program?

What aviation experiences, education, or training do you have to date?

What aviation experiences would you like to gain from your Aerospace Adventures Summer Youth Program experience?

What aviation related career goals do you have that could be further advanced from your experiences at the Aerospace
Adventures Summer Youth Program?

SIGNATURES

Participant __________________________________________________ Date__________________

Parent/Guardian______________________________________________ Date__________________

13450 Lake Fretwell Street, Jacksonville, FL 32221 2

 Application Checklist

STEP I Completed Application Form and Participant’s Letter of Application must be received NO LATER than April 22,
2011 in order for your child to have a complete application to the program.

o Signatures by the applicant, parents and/or legal guardians are required.

o ALL applications are subject to maximum capacities and applicants eligibility qualifications for the
program.

STEP II Please send signed, completed application and Participant’s Letter of Application to:
Aerospace Adventures Summer Youth Program
Aviation Center of Excellence
13450 Lake Fretwell Street
Jacksonville, FL 32221.

STEP III If your child has been accepted into the program, you will be notified by May 2, 2011

A packet of information including the Permission to Participate form, Authorization Release form, Emergency
Medical form, Rules for Participants form, and other pertinent information will be sent.

STEP IV These forms and program payment are due no later than May 20, 2011. Keep a copy of all forms for
reference.

For more information, contact Judith Rice at jrice@fscj.edu or (904-317-3840)

13450 Lake Fretwell Street, Jacksonville, FL 32221 3