Placerita Video Academy Sign Up Form
First Name *
Your answer
Last Name *
Your answer
Gender *
Dates to Attend (Check one or both) *
Required
Street Address *
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City *
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State
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Zip Code
Your answer
Best email to reach you at *
Your answer
Grade in August *
T-Shirt Size (Select One)
All sizes are adult sizes
Parent Guardian Name *
Your answer
Parent/Guardian Cell Phone Number *
include area code
Your answer
Medical Information *
Are there any health problems we should be aware of? If so, please list them and any precautions that should be taken
Your answer
Medical Instructions
Please provide us with any specific instructions you would like us to follow in case of illness or accident.
Your answer
Hold Harmless Agreement *
In the event of an accident, illness, or injury, and the person listed above cannot be reached; I hereby give the RoboMedia personnel permission to take action as deemed necessary in the best interest of my child. Furthermore, I do not hold RoboMedia, its sponsoring agencies, and/or its staff or representatives responsible for injuries to my child, which could occur due to the nature of the activity in which my child is engaged. I also understand that the RoboMedia staff reserves the right to terminate the participation of any student when it is deemed in the best interest of either the student or the summer camp programs.
Required
Emergency Contact *
In case of emergency, please notify:
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Emergency Contact Phone Number *
Please put area code first
Your answer
Camper Photo/Video Release Agreement *
The RoboMedia staff takes numerous photos/videos of students involved in all our activities. We sometimes use these photos/videos in promotional materials for the RoboMedia program, such as brochures, newsletters, videos or websites. In order to include your child’s photo in any RoboMedia project, we must have your signed permission. If you agree to such use, please check the box below. I hereby grant permission for my child to appear in a photograph, video, or digital imagery that will be used by RoboMedia. RoboMedia will hold any and all rights to include these images, in any format or media, and to grant permission for its use in outside publications, including non-government television or cable stations. Student images will not be used for commercial purposes.
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