MoTTU 2017 Summer Camp Registration 4 - 9 age
Please fill out one from per child. For any questions or concerns, please contact Tiffany Demmon at museum.education@ttu.edu or call (806) 742-2432
Email address
Parent/ Guardian Name
Your answer
Address
Your answer
City
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Zip
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Phone Number
Your answer
E-mail
Your answer
Student's Name
Your answer
Student's Age
Your answer
Student's Gender
List any illnesses, allergies, medical conditions, and/or behavior issues of which Museum staff should be aware. (Confidentiality will be maintained)
Your answer
Consent to Medical Treatment: By printing your name below, you the Parent, Managing Conservator, or Guardian consent to any and all emergency medical treatments needed by said Minor Child as administered by a clinic or attending physician and accept responsibility for full payment of said treatment. I give my permission for this document to be photocopied for medical personnel. *
Required
Consent to Media Coverage/Participation: I herby give permission for the name of the name of the minor listed below to be released to the media or for him/her to participate in any media coverage which might transpire during the course of the program. I authorize the use of the minor's name, biography, likeness, voice, and performance in the production of the program(s) and for the purpose of the publicizing and promoting the program(s) and/or future related programs. I represent that I am a parent (guardian) of the minor whose name is listed below and I hereby agree to have my child participate in media coverage. *
Release and Hold Harmless Agreement: I the Parent, managing Conservator, or Guardian, understand that the minor child has the opportunity to participate in camp(s), programs for students sponsored by Texas Tech University, Museum of Texas Tech University, Lubbock, Texas. I hereby affirm that I desire to have my minor child participate in said program. I understand that my minor child will participate in general education and camp activities during this program. I am aware of the dangers associated with such activities and the possibility of injuries or even death in such participation. In consideration of allowing my minor child to attend the above mentioned activities I, the undersigned, do hereby release, indemnify, and hold harmless Texas Tech University, its Board of Regents, all the universities officers, agents, and employees, and the Institute of the Development and Enrichment of Advanced Learners from any and all liability due to injuries, damage or death arising or resulting from any act or omission, express negligence, or otherwise, of said Texas Tech University officers, advisors, agents, and employees and other officers or members of the Institute for the Development and Enrichment of Advanced Learners, or any other person or participant in said activities while attending the activities. In terms, hereof shall also serve as a risk for my minor child's errors. Executor and administrator, and for all members of my child's family and be pleaded as a bar to litigation. Jurisdiction to this matter and venue shall lie in Lubbock, Lubbock County, Texas. I, undersigned, on behalf of my minor child agree to indemnify and hold Texas Tech University, its Board of Regents, and all the universities officers, agents, and employees, harmless from and against any and all personal injury. I am above the age of (18) years and read this Release Hold Harmless Agreement and voluntarily understand and accept its terms. *
Required
Release Agreement: Please fill out the information below relating to those persons who have permission to pick up your child from camp. If, due to unforeseen circumstances or an emergency, it is necessary for someone else to pick up your child, a note from the parent or a telephone call is necessary. Please be aware that the person may be asked to identify himself/herself before we release your child. If there are any custody issues we must have legal documents with regard to who can pick up your child. Please provide Name and Phone Number. *
Your answer
Please check which camp you would like to register your child.
Required
All camps, unless otherwise specified, are $30.00 per child per camp. You may pay in person at the Museum of Texas Tech University, Education Division, 2 weeks before the first day of camp. Please specify payment type below.
Required
I certify that the above information is correct to the best of my knowledge. (Please print name below) *
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A copy of your responses will be emailed to the address you provided.
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