Presented By:

 

 

 

 

 

 

 

 

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Thank you for your interest in this year's Girls in Science program!

 

 

 

This event will be held at Eastern Oregon University from 8:30 A.M.- 3:30 P.M. on Saturday, October 26th.

 

Girls in grades 6-8 from counties throughout Eastern Oregon are eligible to apply.

 

 

Please read these application instructions before proceeding:

 

 

Parents must help their student(s) complete this application. Be sure to complete a separate application for each student who is interested in attending Girls in Science.

 

Note that this is to be filled out at home to ensure applicant commitment and interest: Teachers/schools may not complete this form for their students.

 

 

*Also, be aware that completing this application does not guarantee a student's admission to our program.

 

Interest always exceeds capacity, with only 100 spaces available for Northeast Oregon Area Health Education Center's entire 11-county region. Selection is based a variety of factors including students’ order of application and past participation (preference is given to first-time Girls in Science participants). We also have guaranteed spots available for each county in the region to make sure that all areas are represented.

 

 

Finally, be sure to watch for our emails. All program decisions and updates will be communicated electronically. 

 

 

Contact Brittany Hargrove at (541) 962-3422 or bhargrove@neoahec.org with any questions.

 

 

Thank you!

 

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Girls in Science Application

 

***Important***

 

Only select "1" for the quantity option below. Each student must register and pay separately, even if there are multiple applicants in the same family.

Quantity
Price
Total
Number of Students Applying
X
$
10.00=
$
0

Student Contact Info

Country*
Student Email Address: **If you are submitting separate applications for more than one child, be sure to use a unique student email address for each one. This eliminates the creation of duplicate accounts in our database.*
Confirm Student Email (Same as Above)*
Student Phone Number*

Student Background

Have you participated in any of the following NEOAHEC programs? If so, select all that apply below.
  • Girls in Science
  • Saturday Science
  • NW Noggin
If you participated in Girls in Science in the past, which year(s) did you attend?
  • 2017
  • 2018
Birthdate (mm/dd/yyyy)*
School Name*
Student Career Interest
If this student has any food allergies or special dietary needs that would need to be accommodated at Girls in Science, please describe here.

Parent Information

Parent 1 Name (First and Last)*
Parent 1 Phone*
Parent 1 Email*
Parent 2 Name (First and Last)
Parent 2 Phone

Medical Treatment Information and Release

If this student has any medical issues, please describe.
Please list any medications the student is currently taking. Be sure to indicate when they are administered each day.
Is this student allergic to any medications? If so, list here.
Student's Insurance Company
Student Insurance Policy/Group Number
Student Insurance ID Number

Occasionally, there is a need for immediate medical attention due to a sudden illness or accident. As you may know, hospitals will not administer medical care without parental/guardian consent. Should your child need any medical treatment or testing, the hospital or clinic must have your permission.

 

Complete the following authorization:

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By typing my name below, I hereby authorize staff members of Girls in Science to provide any routine and/or emergency medical care, as necessary, through the treating hospital, or through the services of a local physician. The authorization shall be effective throughout the duration of the event.
 
By signing below, I also agree to pay all charges incurred for the treatment of illness or injury of my child during Girls in Science. I understand that I have primary responsibility for the payment of all charges, whether or not my child is covered by my health or medical insurance.
Parent/Guardian Signature*
Date (mm/dd/yyyy)*

Photograph and Background Information Release

By typing my name below, I authorize Girls in Science and those acting under its permission or authority to use and publish any photographs or video footage of my child or in which she may be included in whole or in part during her stay at Girls in Science.

 

Girls in Science, Eastern Oregon University (EOU), and Northeast Oregon Area Health Education Center (NEOAHEC) may also use background information from my child's application or from other data collected at Girls in Science for marketing and reporting purposes. I waive any right that I may have to approve the finished product or copy, or the use to which it may be applied.

 

By typing my name below, I release and discharge Girls in Science, EOU, NEOAHEC, and those acting under their permission or authority, from any liability for the use of any video footage or photo of my child.

Parent/Guardian Signature*
Date (mm/dd/yyyy)*

Participant Release

In consideration of being permitted to attend and participate in the Girls in Science event, the undersigned hereby releases, waives, discharges, and covenants not to sue all persons affiliated in any way with Northeast Oregon Area Health Education Center or Eastern Oregon University (hereinafter called “Releasees”), including but not limited to their employees, counselors, officers, advisors, and administrators, for and from all claims and/or all liability to the undersigned and their personal representatives, assigns, heirs, and next of kin for all loss or damage and any claim or damage therefore on account of injury or death to the undersigned or any injury or destruction of property, whether caused by the negligence of Releasees or otherwise while said applicant is for any purpose participating in said Program or any related activity. Furthermore, the undersigned agrees to hold Releasee harmless from all claims, suits, actions, or judgments asserted or brought on account of or related to the applicant’s participation in the above mentioned activities.

 

The undersigned expressly agrees that this release, waiver, and indemnity agreement is intended to be as broad and inclusive as permitted by the laws of the state of Oregon and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. We further release all of said Releasees from any claim whatsoever on account of first aid, treatment, or service rendered to the applicant during the applicant’s participation in the above mentioned activities and hereby consent to the rendering of such medical treatment, as Releasees shall deem appropriate.


By signing my name below, I am signifying that I have read the above authorizations and releases: 1) Medical Treatment/Release 2) Photograph/Background Information Release 3) Participant Release and am fully familiar and in agreement with the contents thereof.

Parent/Guardian Signature*
Date (mm/dd/yyyy)*
Student Signature*
Date (mm/dd/yyyy)*

-OFFICIAL-USE ONLY SECTION-

Admissions Criteria:

 

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Fee Paid (Circle One):  Y      N

 

 

First Time Participant (Circle One):  Y      N

 

 

NEOAHEC Region (Circle One):  Y      N

 

 

County:_____________

 

 

Order of Application Received:___________

 

 

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Application Fee

A $10 registration fee is required for Girls in Science. This includes event materials, snacks, lunch, and a t-shirt.

 

In the event that your child is not selected to attend Girls in Science, this fee will be refunded.

 

 

Refunds will not be issued for cancellations after October 11th.

 

Payment Information

Amount*
$
Payment Type
We only accept credit/debit card payments. After you complete this form, select Submit to enter your card details into our secure transaction processor. Your submission will be processed when you finalize your secure payment information.
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