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Daytona State College assures equal opportunity in employment and education services to all individuals without regard to race, sex, color, age, religion, disability, national origin, genetic information, political affiliation or belief, or marital status. STAY CLOSER, GO FURTHER

DaytonaState.edu

July 13-16, 8 a.m - 4 p.m.Apply to attend Daytona State College’s FREE Cyber Camp! This unique experience teaches computer security techniques, including: ·digital forensics ·browser security ·malware handling ·virtualization and much more You must be entering grades 9-12.

Advanced Technology College1770 Technology Blvd. Daytona Beach Cost: FreeAct now! Applications are required.Seating is limited.

Visit DaytonaState.edu/ace/cybercamp.htmlfor details, or contact (386) 506-4163.

CyberSecurity Camp 2015

Advanced Cyberforensics Education Consortium

Medical Release:Daytona State College requires that the following Emergency Medical Release Form be signed by the parent or legal guardian for each child attending. In an emergency requiring medical attention, for which I shall pay and not hold Daytona State College, CyberPatriot or the Advanced Cybersecurity Education Consortium responsible, I authorize the representatives of Daytona State College’s Athletic and Aquatic programs to take my child to the nearest hospital. I also authorize minor first aid as needed for my son / daughter.

Print Name of Parent / Legal Guardian Parent / Legal Guardian Signature

Does your child have any medical problems of which we should be aware? ❐ YES ❐ NO If “yes,” what?

Is your chid allergic or sensitive to any drugs? ❐ YES ❐ NO If “yes,” what?

Is your child at the present time taking any medications? ❐ YES ❐ NO If “yes,” what?

Is your child allergic or reactive to insect bites or stings? ❐ YES ❐ NO If “yes,” what?

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Cybersecurity Camp Application/RegistrationDaytonaState.edu/ace/cybercamp.html

Please submit the application to:Emily Coppa - Coordinator, Advanced Cyber Education Consortium (ACE)Daytona State College, 1770 Technology Blvd., Daytona Beach, FL 32117P: (386) 506-4163 F: (386) 506-4191

By signing this application, the student and parent /legal guardian agree to the terms of the summer camp and that all information

provided is true and correct:

_______________________________________ _______________________________________ ______________________________

Parent/Legal Guardian Signature Student Signature Date

In addition to this application, you must complete a brief online survey at https://www.surveymonkey.com/s/8FQ5PHR.

Student’s Name Age

Parent/Legal Guardian

Address City State Zip Code

Telephone Number (home) (work) (cell)

E-mail

Emergency Contact Phone (cell)

T-shirt size (choose one): oXS oS oM oL oXL oXXL

Photo ReleaseI give permission and consent for_______________________________ to have his/her picture taken during camp session activities. (insert minor’s name)

I further give permission and consent that any such photographs may be published and used by CyberPatriot, the Advanced Cybersecurity Education Consortium or Daytona State College and its agents, to illustrate and promote the camp experience.

Parent/ Legal Guardian Signature Date