2024 C2 Pipeline Summer Camp Application

Camps are Monday - Thursday from 10am -3pm.

July 8, 2024 - July 11, 2024

July 15, 2024 - July 18, 2024

July 22, 2024 - July 25, 2024

July 29, 2024 - August 1, 2024

August 5, 2024 - August 8, 2024

Lunch and transportation are provided!

Students Can Only Attend One Camp Per Week!

GDYT Students Must Also Complete the GDYT Application and Documents.

Camp Fees:

Students that attend one of our C2 Sites, Camps are Free!

Non C2 Pipeline Schools: Weekly fee: $100

Fields with asterisks (*) are required.

Student Information

First name *

Last name *

Email *

Birthdate *

School Attending in Fall 2024 *

If other, what is your school name

Grade Entering in Fall 2024 *

UIC/Student ID # *

Address line 1 *

Address line 2

City *

State/province/region *

Postal/zip code *

Country *

Gender *

Pronouns

Ethnicity

Hispanic or Latinx

Arab or Middle Eastern

Receives Free or Reduced Lunch *

Shirt Size *

Parent/Guardian Information

First & Last Name *

Relationship to Student *

Phone Number *

Email *

Address *

City *

State *

Zip Code *

First & Last Name

Relationship to Student

Email Address

Phone Number

Emergency Contact

First & Last Name *

Phone Number *

Relationship to Student *

Medical Information

Are there any medical reasons/disabilities that prevent your child from participating in certain physical activities? *

Yes

Allergies

Medical Concerns

Camp Selection(s)

Week 5 Camps (August 5 - 8)

Transportation *

Student will be dropped off and picked up from Wayne State University Campus

Student will ride the bus from one of the C2 Pipeline sites

I hereby give permission for the above student to take part in the Wayne State University C2 Pipeline ("Program") activities, which may include off-campus events, academic assistance, college/career and group counseling, continuing education, recreational programming. If a medical emergency arises, I understand Program staff will secure emergency medical and or emergency surgical treatment for my enrolled child. I understand that I will be responsible for any emergency transportation charges and medical expenses incurred. I voluntarily give my consent to Wayne State University and those acting to their authority on behalf of the Wayne State University C2Pipeline Program to record my child's participation and appearance on video tape, audio tape, film, photograph or any other medium during program activities. Any recording/photo or tape may be used by Wayne State University for education and public relations purposes which may include social media or public access websites. I further give my consent for my child's school to share the student's academic records with the Wayne State University C2 Pipeline Program for purposes of providing educational support and assistance. In addition, I understand that Wayne State University will use participant records only to evaluate my child's individual progress and improvement, as well as to evaluate the impact of the program on my child's achievement and to obtain continued funding for the program. I hereby certify that I have read and do understand the above information, the program rules, and I agree to them. *

I consent

*Parent/Guardian please enter name and date to agree to these terms* *

Date *