Tang Math Camp Registration
Health, Consent & Release Form - To be completed by PARENT or LEGAL GUARDIAN ONLY
Order Number *
Check your confirmation email for the order number associated with your purchase from tangmath.com.
Your answer
Week Registered *
Required
CAMPER INFORMATION
Name of Camper *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Entering Grade *
School Name *
Your answer
MEDICAL INFORMATION
Health Insurance - Company/Name *
Your answer
Health Insurance - Phone Number *
Your answer
Health Insurance - Policy Number *
Your answer
Health Insurance - Policy Holder's Name *
Your answer
Primary Doctor - Name *
Your answer
Primary Doctor - Phone *
Your answer
Please answer the following as it pertains to the camper *
YES
NO
Any allergies or dietary restrictions?
Currently on any medication?
Bringing medication to camp?
Any health problems, now or in the past, that could affect his/her participation?
Any communicable or transferable health-related conditions?
Any emotional or psychological disorders (including ADHD)?
If "YES" to any of the above, or if there is anything else we should know about, please explain in detail:
Your answer
Are the camper's vaccinations and immunizations up to date by his/her school's standards and/or requirements? *
APPLICANT INFORMATION
Parent/Guardian - Name *
Your answer
Parent/Guardian - Phone *
Your answer
Alternate Emergency Contact - Name *
Your answer
Alternate Emergency Contact - Phone *
Your answer
CONSENT AND RELEASE
This application must be completed by the above-named camper's PARENT or LEGAL GUARDIAN ONLY for camper to attend camp. Applicant must click "Yes, I understand" to all of the following release clauses and electronically sign the application, otherwise the camper may not participate in Tang Math camp, and a full refund will be given to the applicant if the registration fee has already been paid.
Medical Release *
I, parent/guardian of the above-named camper, certify that the health history I provided for the above-named camper is correct to the best of my knowledge, and that the camper is fit to engage in all camp activities. In the event of a medical emergency, I hereby give my permission to a Tang Math representative and the physician he/she selects to secure proper treatment, including but not limited to: hospitalization, ordering injections, giving anesthesia, x-rays, tests, treatment, transportation, or performing operations that may be urgently necessary for the camper, and to release reports necessary for insurance purposes. I understand that every effort will be made to contact the camper's responsible parent/guardian. I further understand that if I do not have medical insurance that covers all costs, I will be responsible for those costs.
Liability Release *
In consideration of being permitted to participate in any way in the activities at and to attend Tang Math Camp, I, parent/guardian of the above-named camper, for myself, the above-named camper, my heirs, personal representatives or assigns, do hereby release wave, discharge, and covenant not to sue Tang Math, its officers, employees, and agents, from liability from any and all claims including the negligence of Tang Math, its officers, employees, and agents, resulting in personal injury, accidents or illnesses (including death), and property loss arising from, but not limited to the activities and attendance at Tang Math Camp. The participation in activities at Tang Math Camp carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries. I warrant that my child is physically, mentally, and emotionally fit and able to participate in all camp activities. I also agree to INDEMNIFY AND HOLD HARMLESS Tang Math, its officers, employees, and agents, from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorney's fees, as a result of the camper's attendance and involvement in any activities at Tang Math Camp, including any claim asserted by the camper after he/she becomes an adult. I also acknowledge that I have read the above and understand that I am giving up substantial rights, including the right to sue. I acknowledge that I am signing freely and voluntarily, and intend by my signature to a complete and unconditional release of all liability to the greatest extent allowed by law.
Photo, Video and Audio Release *
I, parent/guardian of the above-named camper, hereby authorize Tang Math to film, photograph, and quote this camper for use on Tang Math's website, social media and other promotional materials. I release Tang Math from any expectation of confidentiality for the camper and attest that I am the parent or legal guardian of the camper and that I have the authority to authorize Tang Math to use their photographs. I acknowledge that since participation in publications and websites produced by Tang Math, is voluntary, neither the camper nor I will receive financial compensation. I further agree that participation in any publication and website produced by Tang Math confers no rights of ownership whatsoever. I release Tang Math, its contractors and its employees from liability for any claims by me or any third party in connection with my participation or the participation of the camper.
Parent/Guardian Release Confirmation *
I, the applicant for this form, do swear and certify that I am the parent or legal guardian of the above-named camper, and have legal authority to complete this application on behalf of the camper. I acknowledge that I have read, understand, and accept all terms and conditions on this application, and warrant the truthfulness of the information provided.
Electronic Signature *
Please type your full name below. By doing so, you are signing this application electronically and agree that this is the legal equivalent of your manual signature on this application.
Your answer
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