REGISTRATION FORM
(Please complete a separate form for each child)
CAMP SESSIONS: $200 Per Week
Additional Camp T-Shirts: $7
I First Name* Last Name* , hereby certify that I am the parent or guardian of First Name* Last Name*, D.O.B.Date* , a minor child under the age of 19 years old, and I consent to his/her participation in the 2023 camp/program being held on the campus of Alabama State University. I understand that participation in this camp and any related activities may involve certain risks and dangers which are known and unknown to me and may result in injuries to the above named minor. I am fully aware of the potential risks and possibility of injury involved with said camp and any related activities and acknowledge that I, personally and on behalf of the minor child named above, assume the risk of such injury by allowing the above-named minor to participate in the camp and any related activities. I further acknowledge that I have health insurance and will be responsible for any and all medical and related bills that may be incurred by the above-named minor child’s participation, including any illness or injury that he/she may sustain during the camp and any related activities. I further acknowledge and authorize the employees or agents of Alabama State University to act according to their best judgment in any situation requiring medical attention for the above-named minor child, whether an emergency or not. Knowing these facts and in consideration of the participation in this camp and nay related activities, I myself, my heirs, my estate, my executors and administrators hereby release, discharge and indemnify Alabama State University, its officers, directors, Board of Trustees, representatives, and employees, from any and all liability, for negligence or any other claim, demand action, judgment, loss, liability, cost and expenses (including without limitations, attorney’s fees and costs) arising out of or in connection with the above camp and any related activities directly or indirectly, including, but not limited to, any illness, injury, damage or loss to person or property that I may incur or sustain during the camp and any related activities. I acknowledge that I am at least nineteen years of age and have carefully read this Release of Liability in its entirety and fully understand its contents. I am aware that this release contains an acknowledgment of my voluntary and knowing assumption of the risk of illness of injury for the above-named minor child. I further acknowledge that I have signed this document voluntarily and of my own free will. I agree that this agreement shall be governed by the laws of the State of Alabama.Signature:Signature* Date: Date* Emergency Contact:Name * Home Phone:Area Code* Phone Number* Cell Phone:Area Code* Phone Number* Camp Name: (Select One)SKYCAP Reimagined (Grades 2-9) Kids Academy - "Tiny Tech Camp" (K-1)
Dear Parent/Guardian:Your child has been afforded the opportunity to participate in field trips.The Release of Liability form MUST be signed by a parent or guardian for your child to participate in the field trips. Transportation will be provided by the University buses. The group will be supervised by the ASU Division of Continuing Education’s staff and accompanied by designated DCE staff & chaperones. Destination: Montgomery Area MuseumsDates of Trips: June 21 & June 28Departure Time: 8:30am & 12:30pm Return Time: 10:30am & 3:30pmComplete this form with your preferenceMy Child, First Name Last Name MAY participate in the above trips.Signature of Parent or GuardianSignature Date My Child, First Name Last Name MAY NOT participate in the above trips.Signature of Parent or GuardianSignature Date The University reserves the right to cancel or change any or all field trips if necessary.
Please answer the following questions:
In case of a medical emergency, who should we contact?
MEDICAL RELEASE CONSENT
I CONSENT TO MEDICAL TREATMENT FOR MY CHILD BY ALABAMA STATE UNIVERSITY HEALTH SERVICES AND/OR LOCAL EMERGENCY SERVICES IF DEEMED NECESSARY BY THE PROGRAM. I UNDERSTAND THAT I WILL BE NOTIFIED OF ANY ILLNESS OR EMERGENCY SITUATION RELATED TO MY CHILD AS SOON AS POSSIBLE AND ACCEPT FULL RESPONSIBILITY FOR ANY UP FRONT CO-PAYMENT AND MEDICAL BILLS THAT MAY RESULT.
The undersigned hereby understands and agrees to the following:
915 S. Jackson Street | Montgomery, AL 36104 | 334-229-8487 | www.alasu.edu