Clone of Summer Camp Registration Form

Summer Academies 2026 Registration

FOR STUDENTS ENTERING 8TH THRU 10TH GRADE IN PIONEER TECH DISTRICT: Complete the form and pay the non-refundable, non-transferrable $25 Academy fee (up to 2 Academies). Deadline for enrollment is one week prior to start of each Academy or until a class is filled. Late applications are permitted only if slots are available. For more information or questions call (580) 718-4234
Student Information
Student's Name*

First NameLast Name
Birth Date

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
MaleFemale
8th9th10th
BlackwellNewkirkPonca CityTonkawaWoodlandOther
NURSING ACADEMY June 8 - 11 (8 - 11am)STEM BIOTECH ACADEMY June 8 - 11 (8 - 11am)SALON ACADEMY June 15 - 18 (8 - 11am)SHORT FILM ACADEMY June 15 - 18 (8 - 11 am)BABYSITTING ACADEMY June 22 - 25 (8 - 11am)YOUTH POLICE ACADEMY June 29 - July 2 (8 - 11am)STEM ROBOTICS ACADEMYJune 29 - July 2 (8 - 11am)WELDING ACADEMY July 6 - 9 (8 - 11am)FIREFIGHTER ACADEMY July 6 - 9 (8 - 11am)METALWORKING ACADEMY July 13 - 16 (8 - 11am)HORSEPOWER ACADEMY July 20 - 23 (8 - 11am)CONSTRUCTION ACADEMY July 20 - 23 (8 - 11am)
Parent/Guardian Information
Name*

First NameLast Name
Cell Number*
Format: (000) 000-0000.
E-mail*
example@example.com
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*
Format: (000) 000-0000.
Alt. Phone Number*
Format: (000) 000-0000.
Current medical conditions/food allergies and medications (please list)
Family Doctor's Name & Phone Number*
Insurance Company & Policy Number*
Photo Release

I give permission for the use of the above participant’s photographic likeness in preparation and distribution of all promotional material including advertising, brochures, displays, public relations activities, pamphlets, signs, still photography, and video promoting the services, classes, and functions attesting to the positive well-being of Pioneer Technology Center in Ponca City, Oklahoma. Conditions of this release state that all photographs remain the property of Pioneer Technology Center. YOU MUST FILL OUT THE FORM COMPLETELY.
Health Release

By my electronic signature below, I give permission for PTC staff to act on my behalf to take measures deemed necessary in the event of sickness or injury during Summer Camp. I agree to pay for any medical expenses for my child whose name appears above.
Nondescrimination Policy

Pioneer Technology Center does not discriminate on the basis of sex, race, color, national origin, disability, age, or any other characteristic protected by law, and prohibits sex discrimination in any education program or activity that it operates, as required by Title IX and its regulations, including in admissions and employment. For inquiries concerning the application of this policy, contact compliance@pioneertech.edu; Wendy Burg, (580) 718-4308 or wendyb@pioneertech.edu; or Kellie Johnson, (580) 718-4224 or kelliej@pioneertech.edu, Compliance Officers/Title IX Coordinators; or Carol Lynes, (580) 718-4298 or caroll@pioneertech.edu, 504/ADA Coordinator. Pioneer Technology Center, 2101 N. Ash, Ponca City, Oklahoma 74601.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

My Products

Academy Registration

$25.00 Quantity

Enter coupon

Total

$0.00

Credit Card

Permission

I give my permission for the above participant to participate in all the Pioneer Technology Center Summer Camp activities.
Date

MonthDayYear
Date
Signature
Should be Empty:

Summer Academies 2026 Registration

Credit Card