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The Health Museum 2022 Summer Discovery Camp Program Scholarship Application FormThe Health Museum is offering 6 summer camp scholarships for the 2022 summer break session.The scholarships are open to students who are or will be aged 5 - 13 as of September 1, 2021, fromthe following school districts:Houston Independent School District (HISD)Fort Bend Independent School District (FBISD)Katy Independent School District (KISD)Stafford Municipal School District (SMSD)Lamar Consolidated Independent School District (LCISD)Alief Independent School District (AISD)Spring Branch Independent School District (SBISD)Pasadena Independent School District (Pasadena ISD)Galena Park Independent School District (Galena Park ISD)North Forest Independent School District (NFISD)Aldine Independent School District (Aldine ISD)Cypress-Fairbanks Independent School District (CFISD)Clear Creek Independent School District (CCISD)Galveston Independent School District (GISD)Texas City Independent School District (TCISD)Dickinson Independent School District (DISD)Students must be interested in learning, have good behavior, and cannot otherwise afford toattend camp. The scholarship includes a full week of tuition only.If you are interested in applying for a scholarship, please follow the steps below:1. Fully complete the application. There are 3 total pages (1 page for parent guardian and 2 pagesfor teacher/staff recommendations. Please have teacher/staff members complete and submitrecommendations.2. Submit a written letter stating why you would like to attend the 2022 Summer DiscoveryCamp Program.3. Mail this completed application to The Health Museum - CAMP OFFICE, 1515 HermannDrive, Houston, Texas 77004. You may also email the form as an attachment [email protected] It must be received on or before April 15, 2022.4. Be prepared to attend camp the weeks that you specified. If you are awarded a scholarship, thatspot is reserved for you alone. It cannot be transferred to another student if you are unable toattend.5. Applicants awarded scholarships will be notified by email the week of April 22,2022 or before.Scholarships are made possible through the Kenneth Mattox Scholarship Fund.For a complete listing of camp classes visit www.thehealthmusuem.org

The Health Museum 2022 Summer Discovery Camp Program Scholarship Application FormCAMPER INFORMATION PLEASE PRINT NEATLYCamper’s Name: M/F:Age/Grade: /School District: School:Parent’s Name: Email:Address: City: State: Zip Code:Day P Cell Phone: Evening Phone:Other Parent/Emergency Contact: Relationship to Camper:Day Phone: Cell Phone: Evening Phone:GENERAL RELEASE & CONSENT PLEASE READ & PRINT NEATLYThe Health Museum General Release and Consent for 2022 Summer Discovery CampThe Health Museum is offering camps in its Discovery Camps Program. While every preventative measure will betaken, injuries may occur during a camper’s participation in the 2022 Summer Discovery Camps Program. This is arisk that the camper and his/her legal guardians voluntarily agree to assume in exchange for the privilege ofregistering for and participating in the chosen camp(s). The camper and his/her guardians understand and agreethat this risk is one that The Health Museum does not assume and that the Health Museum is not responsible forany injuries to the camper. Accordingly, (the “guardian”), the legal parent or legal guardianof (the “camper”) voluntarily releases The Health Museum and its directors, officers,employees, volunteers, agents, and all persons acting by, through, under or in concert with The Health Museum(collectively called the “Released Parties”) from any and all losses, demands, claims, suits, causes of action,liabilities, costs, expenses, and judgments whether arising in equity, at common law, or by statute, under the lawof contracts, torts, or property, for personal injury (including without limitation emotional distress), arising in favorof the guardian or the camper based upon, in connection with, relating to or arising out of, directly or indirectly,the camper’s participation in the camp (collectively called “Claims”) AND EVEN IF ANY SUCH CLAIMS ARE DUE TOTHE RELEASED PARTIES’ OWN NEGLIGENCE, STRICT LIABILITY WITHOUT REGARD TO FAULT, VIOLATION OFSTATUTE OR OTHER FAULT. The guardian and the camper hereby give their permission to the Released Parties toseek emergency medical treatment for the camper if any Released Party deems in its discretion that suchemergency medical treatment is necessary.Parent/Guardian (Printed Name) Signature DateFor a complete listing of camp classes visit www.thehealthmusuem.org

The Health Museum 2022 Summer Discovery Camp Program Scholarship Application FormTEACHER or STAFF RECCOMENDATIONS: Please give this form to two teachers or school staffmembers who can recommend you for camp. Teacher or Staff recommendations factor intoscholarship selection.Print and mail this completed application The Health Museum - CAMP OFFICE, 1515 HermannDrive, Houston, Texas 77004. OREmail the form as an attachment to [email protected] completed application must bereceived on or before April 15, 2022.TEACHER / STAFF MEMBER 1NAME:POSTION AT SCHOOL: School/District /Name of Student: Age Grade LevelHow long have you known the student?Does the student have a financial need for the scholarship?Does the student qualify for free or reduced school meals?How would you rate the following aspects of the student?BehaviorLowest123Highest45Willingness to learn12345Willingness to participate12345Aptitude for science12345Ability to adapt to a new environment12345Additional Comments:Please make any additional comments you feel necessary to demonstrate the student’s emotional, intellectual orfinancial need for the scholarship opportunity being offered.For a complete listing of camp classes visit www.thehealthmusuem.org

The Health Museum 2022 Summer Discovery Camp Program Scholarship Application FormTEACHER or STAFF RECCOMENDATIONS: Please give this form to two teachers or school staffmembers who can recommend you for camp. Teacher or Staff recommendations factor intoscholarship selection.Print and mail this completed application The Health Museum - CAMP OFFICE, 1515 HermannDrive, Houston, Texas 77004. OREmail the form as an attachment to [email protected] completed application must bereceived on or before April 15, 2022.TEACHER / STAFF MEMBER 2NAME:POSTION AT SCHOOL: School/District /Name of Student: Age Grade LevelHow long have you known the student?Does the student have a financial need for the scholarship?Does the student qualify for free or reduced school meals?How would you rate the following aspects of the student?BehaviorLowest123Highest45Willingness to learn12345Willingness to participate12345Aptitude for science12345Ability to adapt to a new environment12345Additional Comments:Please make any additional comments you feel necessary to demonstrate the student’s emotional, intellectual orfinancial need for the scholarship opportunity being offered.For a complete listing of camp classes visit www.thehealthmusuem.org

Discovery Camps Summer 2022 Student Financial Aid ApplicationApplication Instructions to Primary Contact/Parent/Guardian Completing This Formyy Aid awards are based on need.yy Apply early—financial aid funds are limited.yy Applications that do not include all required documentation cannotbe processed.Household informationStudent’s Name(First)(MI)(Last)Please provide contact information for the parent or guardian staff should contact if they need additional information to process your application.Primary Contact Mother Father GuardianName Dr. Mr. Mrs. Ms.Email Address County of ResidenceOccupation Daytime Phone ( ) -Employer NameParents’ Marital Status Single Married Domestic Partnership Separated Divorced WidowedIf parents are divorced or separated, student lives most of the time with Mother/Guardian Father/GuardianIf you own your home, current value of your home . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Balance of associated loans. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Does the student participate in a free or reduced lunch program at school? Yes No N/A or home schooledDo you or any people living in the student’s main household (including grandparents, other relatives, or friends) receive:Social Security payments?SSI payments?Child Support payments?Unemployment compensation? Yes Yes Yes Yes No No No NoWelfare, TANF, or other public assistance payments? Yes NoIf yes, /monthIf yes, /monthIf yes, /monthIf yes, /monthIf Yes, please list the type of benefit(s) and amount(s) below: /month /month /monthRequired AttachmentsA signed copy of your 2020 Federal Income Tax Return (Form 1040, 1040A, or 1040EZ) along with the forms and schedules listed belowthat you submitted with your return. Please send only the requested forms and schedules. Form 1040, 1040A, or 1040EZ Schedule A Form 4562 Schedule C and /or F W2 forms Schedule D Schedule EMarried parents living in the same household, separated parents, and stepparents filing separate tax returns must submit tax forms for bothparents. Divorced parents may submit tax forms for the custodial parent only.I declare that I provided accurate and complete information in this application.Signature of Primary Contact/Parent/GuardianSubmit this form and documentation by e-mail to [email protected]

Discovery Camps Summer 2022 Student Financial Aid ApplicationPreferencesStudents may apply for one class per summer. Please only rank the classes that you are willing to take in order of preferencefrom 1-3, with 1 being your first choice.June 6-10Mini ChemistJunior ChemistSenior ChemistJuly 18-22Mini ChemistJunior ChemistSenior ChemistJune 13-17DNA DiscoveriesForensic ScienceGirls Rock Steam CampJuly 25-29The Clinic IGrossed Out ScienceMini Medical School IJune 20-24The ClinicGrossed Out ScienceMini Medical School IAugust 1-5The Clinic IIGirls Rock Steam CampMini Medical School IIJune 27-July 1The Clinic IICamp NeuronMini Medical School IIAugust 8-12DNADiscoveriesCamp NeuronMini Medical School IIJuly 5-8Mini VetJunior VetSenior VetAugust 15-19Mini VetJunior VetSenior VetJuly 11-18Mini Chef AcademyKitchen Chemistry (8-13)How would you (student) describe yourself ethnically? (optional)Black/African AmericanNative American/Alaskan NativeWhite/CaucasianAsian-American/Pacific IslanderLatino/HispanicOtherGender (optional)MaleFemalePlease list any allergies below:Signature of Primary Contact/Parent/GuardianSubmit this form and documentation by e-mail to [email protected]

The Health Museum 2022 Summer Discovery Camp Program Scholarship Application Form The Health Museum is offering 6 summer camp scholarships for the 2022 summer break session. The schola