Camper Information: Name:___________________________________ Date of Birth: ____________________

1. FOR OFFICE USE ONLY: Date received: ______ Payment Type:______ Confirmation: ______ Energy Camp Louisiana 2013 Camp Dates & Locations: (select one) June 3-7, 2013 at Southern University at Shreveport (Caddo Parish students) June 10-14, 2013 at Bossier Parish Community College (Bossier Parish students) July 8-12, 2013 at Northwestern State University (Desoto, Natchitoches, & Red River Parish students) Camp Hours: 8:30a-4:00p Mon.-Thurs; 8:30a-1:30p Fri. This camp is for incoming 10th, 11th, and 12th grade students! If you are under the age of 18, this form MUST be completed by a parent or legal guardian. DEADLINE: May 10th Camper Information: Name:___________________________________ Date of Birth: ____________________ Address: _________________________________ Male Female City: ____________________________________ E-mail Address _________________________ State & Zip: ______________________________ Home High School: ____________________ Home Phone: ____________________________ T-Shirt Size:_____________________ Student Cell Number:______________________ Transportation needed: yes no Current Grade as of 6/1/13: _______________ Request need-based scholarship info: How did you hear about the camp:____________________________________________________ Parent/Guardian Information: Parent/Guardian’s Name:___________________________________________________________________ Home Phone Number:_____________________________ Cell Phone Number: ________________________ Work Phone:_____________________________ E-mail Address: _____________________________________ $25.00 non-refundable registration fee (need-based scholarships available) Easy to register: Mail or In-Person – Mail or Bring Printable Registration Form and payment (Check or CC) to: LSUS, One University Place, BE-119, Shreveport, LA 71115 Fax—Fax the Printable Registration Form and payment to 318-795-2489 Name on CC or Check: ________________3-Digit Security Code: Check or CC #: _________________CC Type: VISA/MC/AMEX/DISCOVER Expiration Date: _________ I give permission for my son/daughter to attend Energy Camp Louisiana. Name of Parent/Guardian:__________________________________________________________ Signature of Parent/Guardian:____________________________________________________ Student slots are assigned in order of receipt. We will notify you and return fees immediately if your camp fills. Call 318-795-2485 for more information. GET CONNECTED: