TKU/Wagner REGISTRATION
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Student Name *
Student Cell Phone Number
Parent/Guardian Name *
Address
Email Address *
Phone Number *
Age of Student
School Name
Grade
Interests
Is your child able to communicate verbally? *
Please check any that are applicable to your child that our teachers/leaders may find helpful to support your child: *
Required
Is there anything else we need to know about your child? (food restrictions, allergies, medications, other)
I give permission for my child to be photographed/videotaped during the course of the workshop for publicity purposes.
Clear selection
In regard to travel, my child will
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RELEASE, CONSENT AND WAIVER
In consideration of the above named person being permitted to participate in Tech Kids Unlimited at Wagner College with Learning Differences (“Event”), sponsored by Wagner College via the New York Community Trust Fund, taking place in 2014 respectively, the undersigned does hereby agree to assume all the risks and responsibilities surrounding such participation or any activities, including transportation, undertaken as an adjunct thereto; and further, for myself, my heirs and personal representatives, I hereby agree to defend, hold harmless, indemnify and release forever, and forever discharge Wagner College and all its officers, agents and employees from and against any and all claims, demands and actions or causes of action, on account of damage to personal property, or personal injury, or death which may result from the aforesaid participation and transportation activities incident thereto. I hereby grant to Wagner College the right to photograph and/or videotape me during my participation in the Event. I further grant to Wagner College the right to use these photographs and videotapes of my likeness, voice and sounds during my participation, and to reuse or license the right to reuse such photographs and videotapes of my participation, and my name, likeness and biography, as Wagner College may desire, in all media and in all forms and for all purposes, including without limitation, advertising and other promotions for Wagner College without further compensation to me or any limitation whatsoever. In the event I should sustain injuries or illness while involved in the Event, I hereby authorize Wagner College to administer, or cause to be administered, such first aid or other treatment and medications I may bring as may be necessary under the circumstances, to include treatment by a physician or hospital of Wagner College's choice. Further, it is hereby certified that the above-named Participant has no medical or psychological conditions, which would preclude such participation.
Initial below to agree to the above release, waiver, and consent
Name
Cell Phone Number
Home Phone Number
Work Number
Workshops That You Plan To Attend *
Check any that you are interested in attending
Required
Are you interested in pursuing a need-based scholarship for the program? *
(The program fee is $20 per workshop)
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