2015 Video Game Design Experience
6th-8th Grade Students
January 31st – March 28th
LOCATION: Gateway Technology Center
(On North Carolina Wesleyan College’s Campus)
The ECU/NC State University Collaborative at the Gateway Technology Center (GTC) is offering this five session
video gaming experience in partnership with the NC State College of Engineering for middle school students
(6th- 8th graders). The GTC is located on the campus of NC Wesleyan College in Rocky Mount. No previous
experience is necessary. The individual projects will be adapted to each student’s skill levels.
To download the informational flyer or to print the application and waiver forms go to The ECU/NC State
Collaborative’s website at:
www.gatewaytechnologycenter.com
Additional questions? Contact Susi Price at susileighprice@gmail.com or call 910-548-4019, or contact the
ECU/NC State Collaborative office at 252-446-2585.
When: The following five Saturdays from 9am to Noon:
January 31
February 14th and 28th
March 14th and 28th
Cost:
$50 per student. (NOTE: No partial payments for individual sessions will be considered.)
Send no money at this time. Your $50 registration fee will be due after you have been notified of
acceptance.
Application Process:
1) Complete the application and waiver forms.
2) Student should complete a brief essay on why she/he would like to attend this program.
This essay is very important in the selection process. The student should take their time
composing it. Please limit the essay to no more than two paragraphs.
3) Mail the completed application, waiver forms (pages 1-4), and brief essay in one package to:
ECU/NC State University Collaborative
Video Game Design Experience
3400 N Wesleyan Blvd
Rocky Mount, NC 27804
The complete application, waiver forms, and student essay are due to Susi Price on or before
5pm on December 12th.
Notification of admittance will be by 5pm December 19th. If you have not heard from the ECU/NC State
Collaborative by this time please call 252-446-2585 and request your student’s status.
Video Game Design Experience
APPLICATION and WAIVER forms to be returned by December 12th – Page 1 of 4
Personal Information
Please print clearly
Child’s First Name ___________________________________________Last Name_____________________________
Address
Street_____________________________________________
City ________________________ State______Zip Code_________County of Residence____________
Child’s birth date ______/______/________
Ethnic Background (please check all that apply)
___African-American ___Asian ___Caucasian
___Other ________________________________
_____ Hispanic
___Native American
School Information
Name of School________________________________________________
Current grade __________6th __________7th __________8th
Please enter your student’s letter grade from their last report card (A, B, C, …)
Math _________
Science __________
Have you ever attended an NC State activity/camp in Rocky Mount?
_________No
______Yes (if yes, what year/s_____________)
How did you hear about the Video Game Design Experience?
___School Counselor ___Newspaper ___School Teacher ___Other (Please explain______________)
Emergency Contact Information
Parent/Legal Guardian and primary emergency contact
Name _________________________________________________________
Phone - Daytime__________________________Evening___________________________
Parent/Legal Guardian email address __________________________________________
Alternate Emergency Contact if we are unable to reach the primary parent/guardian:
Name_______________________________________________________
Phone_______________________________________________________
Parent/Guardian Consent and Liability Release
I _____________________________ as parent/legal guardian of _______________________________ hereby grant the
permission necessary to allow my child to participate in the above activity and agree to all terms and conditions stated in
the application and waiver forms. All information provided is accurate. I, in my own behalf and on behalf of my above
named child agree to release and to hold harmless the ECU/NC State Collaborative and staff associated with this
program from any and all liability, whether caused by negligence or otherwise for any claim, judgment, loss, liability, cost,
and expenses arising out of or connected with the activity including claims connected with injury or illness (minimal,
serious, catastrophic, and/or death) that my child may incur or sustain during the activity/activities associated with the
program. I further expressly agree to indemnify and hold harmless ECU/NC State Collaborative and the associated
universities and associated staff from further claims, demands, or actions that may be brought by me or my child or any
other persons on account of damages of any form resulting to my child in any way from the forgoing activities.
I on my own behalf and on the behalf of my child have read this liability release in its entirety and fully understand its
contents. This release is an acknowledgement of my knowing and assumption of risk of injury or illness and sign this
document voluntarily and of my own free will.
X
Parent / Guardian Signature ________________________________ Date ______________
Video Game Design Experience
Page 2 of 4
Medical Release Information
Any medications my child is taking or medical conditions my child has are listed below including any and all allergies. If
necessary my child will bring medications with him/her to the camp and will consume the prescribed dosage of said
medications.
Medications (Include name, dose, and frequency) _____________________________________________________
Allergies ______________________________________________________________________________________
List Medical Conditions or Concerns _______________________________________________________________
Date of Last Tetanus Booster: _______________________________
Family Doctor Name ______________________________________ Phone ______________________
Insurance Company ______________________________________ Phone _______________________
Policy Number ___________________________________
Medical Release
I, in my own behalf and on behalf of my child, acknowledge and agree that participation in an ECU/NC State Collaborative
activity may result in possible physical injury or illness (minimal, serious, catastrophic, and/or death) and acknowledge the
risk of illness or injury resulting in participation. I authorize the program’s staff to obtain any necessary medical treatment
for my child. I understand that I will be responsible for all medical and related bills that may be incurred during the
participation of this program.
X
Parent / Guardian Signature ________________________________ Date ______________
Photo Release
During this program photographs and videos may be taken of your child. This media may be used for
promotional purposes and in other university publications. At times, members of the news media or
others associated with documenting our activities may also be present to take pictures or video.
 I give my permission for my child to be photographed or videoed while participating in this
activity.
 I do not give permission for my child to be photographed or videoed while they are participating
in this activity.
Video Game Design Experience
Page 3 of 4
Guidelines and Expectations
Please review the conduct expectations listed below. These expectations are meant to ensure that your child
and all others have a safe and enjoyable time during this program.

Any student whose behavior disrupts or interferes with your child’s experience or the experience of
others may be asked to sit out of activities and/or be required to go home. Should a student not
respond positively to requests for positive behavior they may be asked to go home and not return to
camp.

Any items that might cause injury to your child or others are not to be brought to the Gateway
Technology Center. Items of this nature will be confiscated and returned at the end of the day.

Electronic devices of any kind, other than cell phones, should be left at home. Students must ask
permission to use their cell phones while participating in the ECU/NC State programs. Students whose
parents/guardians agree to allow them to keep a cell phone with them during a program agree that they
are responsible for them and will confine cell phone use to parent contact only at appropriate times.
Students agree that any emergency contact with parents should only be done by a staff
member.

Hitting, kicking, pushing, or any action that could be seen as bullying will not be permitted.

Students are expected to speak politely and appropriately to other students and staff at all times.

Working together and cooperatively is sometimes difficult but something we need to learn to do.
Students are expected to cooperate with one another or seek the assistance of a staff member to help
with any cooperation issue or problem at camp.

Please follow the school dress code to participate in this activity.
Students and their parents/guardians are required to attest that they have reviewed these expectations by
signing below. Students must also agree to do their best to follow these guidelines and understand that their
parents may be contacted to help deal with any problem or issue that arises.
In light of the Guidelines and Expectations, I agree to the following:
I acknowledge and understand that the guidelines and expectations pertain to all aspects of the program and
use of facilities, equipment, and materials. My child and I have reviewed the conduct and behavior
expectations that have been provided and agree to abide by them. My child will be responsible for his or her
failure to abide and fully understands any violation can result in dismissal from program with no refund. I
further agree to be responsible for immediate transportation should dismissal occur.
X
Student Signature: ________________________________________ Date: ______________
X
Parent / Guardian Signature: ________________________________ Date: ______________
Video Game Design Experience
Page 4 of 4
Student Survey Consent Form
MISO Student Consent Form/NC State University
STEM Program Name: Video Game Design Experience
Title of Study: MISO: Maximizing the Impact of STEM Outreach through Data-Driven Decision-Making
We are conducting a research study to examine the impact that NC State outreach programs have on student attitudes toward
and interest in Science, Technology, Education, and Math (STEM) education and careers.
Information
In this study, you will be asked to: complete an online or paper and pencil survey and authorize researchers to access your
student’s educational information that is collected by the NC Public Schools. The survey will ask you to give information about
your attitudes toward STEM and interest in STEM college degrees and careers. You will need approximately 30 minutes to
complete the survey. Surveys will be administered during your outreach program. You will be asked to put your name on the
survey to facilitate the connection of your survey to a larger database. Names will not be used in data analysis or reporting, and
will be replaced with code numbers before data analysis is completed.
Risks and Benefits
No foreseeable risks or discomforts are expected from your participation in this study. Survey data will be summarized and no
data will be identifiable by your name. Findings from this survey will be used to improve the outreach program that you are
participating in, as well as other outreach programs through NC State University.
Confidentiality
The information in the study records will be kept strictly confidential. Survey data will be stored securely in password-protected
Web forms. No reference will be made in oral or written reports which could link you to the study. Information you provide will not
have an impact on your academic standing and what you say will not be reported to any faculty members or administrators. Code
numbers linked to your name will be used so we can match your survey responses to the larger database of this study. Outreach
program providers will be allowed to see aggregate results of survey data of the participants in their program. Outreach providers
will not be able to identify individual students. For protection of confidentiality, if paper and pencil surveys are administered (rather
than online) they will be collected from you (the student) in sealed envelopes for delivery to the MISO project team.
Contact
If you have questions at any time about the study or the procedures, you may contact the researchers, Jeni Corn, Friday Institute
for Educational Innovation at North Carolina State University, Raleigh, 27695, or (919-513-8527). If you feel you have not been
treated according to the descriptions in this form, or your rights as a participant in research have been violated during the course
of this project, you may contact Deb Paxton, Administrator of the NCSU IRB for the Use of Human Subjects in Research
Committee, Box 7514, NCSU Campus (919/515-4514).
Participation
Your participation in this study is voluntary; you may decline to participate without penalty. If you decide to participate, you may
withdraw from the study at any time without penalty and without loss of benefits to which you are otherwise entitled. Choosing to
participate or not in this study will not affect your standing or grades in this outreach program or school. If you withdraw from the
study before data collection is completed your data will be returned to you or destroyed at your request.
Consent to Participate (Please check one)
_______Yes, I agree to have my child participate in this survey but may withdraw them at any time.
_______No, I decline to have my child participate.
Student Name (please print) _______________________________________________________
Parent's Signature _______________________________________________ Date: ___________
“I have read and understand the above information. I have received a copy of this form. I agree to participate in this
study with the understanding that I may withdraw at any time.”
For University Use Only:
Investigator’s Signature____________________________________________Date:_____________