Youth Symposium

STUDENT APPLICATION/PERMISSION FORM 2025-2026

Georgia National Guard Youth Symposium 2026 Aug 21-23

* Indicates required field

Student's Name *

First

Last

Date of Birth *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Parent's DoD Affiliation (Unit or Civilian Status) *

Authorized Drop-Off/Pickup Adults *

Please put anyone's name that can drop-off/pickup your child during camp. Campers will not be released to anyone not named on this list. If you need to add someone to the list, please let us know beforehand.

Medical Release

Please note any food or medical (allergies, illnesses) or accommodations needed at camp. *

In case of emergency, I authorize STARBASE and or the accompanying chaperone to obtain medical aid for my child as ward, as they deem necessary. I agree that the cost of such medical care is my responsibility or that of my child's health insurer.

I acknowledge the medical release above. *

Acknowledge

Signature of Acknowledgement *

First

Last

Student's are required to bring their own lunches from home during the week of camp, but we will have snacks provided. Please let us know any allergies in the information box above.

Parent & Emergency Contact Information

Parent/Guardian & Emergency Contact 1 *

First

Last

Email *

Cell Phone *

Home Phone *

Parent/Guardian & Emergency Contact 2 *

First

Last

Email *

Cell Phone *

Home Number *

Student Release of Liability

I hereby grant permission for the aforementioned minor to participate in the Peach State Youth Symposium program. I understand that participation is voluntary, and subject to the Code of Conduct on the back of this form. I also
acknowledge that photographs and video may be used to document and promote Peach State Youth Symposium activities and hereby consent to use of photographs of the aforementioned minor for these non-commercial purposes. I understand that
as a parent/guardian of a Youth Symposium student, I am financially responsible for damage to government property. I further agree not to hold the United States Government, State of Georgia, Dobbins Air Reserve Base, Clay National Guard Center, Georgia Department of Defense, its officers, employees, and agents, Youth Symposium, Cobb County Schools or Marietta City Schools, or volunteers supporting the program liable for any reason as a result of participation in the
program.

Parent/Guardian Signature *

First

Last

Date *

Youth Symposium Code of Conduct

To ensure that your Youth Symposium experience is a positive and enjoyable one for all
participants, it is necessary to establish and enforce a high standard of behavior. All student
participants in Youth Symposium academies by virtue of their signed permissions and consent form
on the other side of this application, OR their signature below, agree to abide by the following
Code of Conduct:

I WILL:
•Be courteous and respectful towards others, including my fellow students, teachers,
and Youth Symposium instructors & volunteers;
Participate positively and to the best of my abilities in each lesson and activity;
•Work cooperatively as a member of a team in all lessons and activities;
•Value and respect others’ ideas, regardless if they are the same or very different than
my own;
•Follow the directions and instructions of Youth Symposium instructors and volunteers;
•Be respectful of all equipment, facilities and property of Youth Symposium, taking care to
leave it all in as good a shape as you found it.

Violations of this Code of Conduct will result in corrective and/or disciplinary actions. The levels of actions
may include:
•Immediate verbal correction by a Youth Symposium instructor or volunteer;
•Temporary removal from the classroom, lesson or activity for corrective
verbal action by a Youth Symposium instructor or school teacher;
•Referral to the Director, Peach State Youth Symposium, for serious or repeated
offenses.
The Director may, at his or her discretion:
•Suspend a student from a given lesson or activity
•Suspend a student from all lessons and activities for a set amount of time
•Expel a student permanently from all Youth Symposium lessons and activities

I acknowledge that myself and my child have read and discussed the Youth Symposium code of conduct. *

Acknowledge

Parent/Guardian Signature *

First

Last

Student Signature *

First

Last

Submit