2023 SKYCAP REIMAGINED SUMMER CAMP REGISTRATION FORM

REGISTRATION FORM

(Please complete a separate form for each child)

CAMP SESSIONS: $200 Per Week

Additional Camp T-Shirts: $7
Please select the session(s) that your child will attend camp*

Week 1 (June 12-16)Week 2 (June 20-23)Week 3 (June 26-30)
Student’s Information
Name*

First NameLast Name
Grade (1-6)*
Age*
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale
Student's T-Shirt Size*
Parent/Guardian’s Information
Parent/Guardian's Name*

First NameLast Name
Parent/Guardian's Name

First NameLast Name
Address*

Street Address

CityState / Province

Postal / Zip Code
Day/Work Phone*
Please enter a valid phone number.
Cell Phone*
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Email*
example@example.com
Alternate Contact #1*
Alt. Contact #1 - Phone Number *
Please enter a valid phone number.
Alternate Contact #2*
Alt. Contact #2 - Phone Number*
Please enter a valid phone number.
SKYCAP Information:
How did you hear about SKYCAP / Kids Academy / ASU Youth Programs?*

Alumni/Friend/ASU EmployeeBrochure/BillboardParent MagazineRadio/TVWebsiteGoogleSocial MediaOther
Is this your child's first time participating in SKYCAP?*

YesNo
What school did your child/children attend during the 2022-2023 academic year?*
Are you interested in additional Continuing Education classes for youth or adult learners?*

YesNo
RELEASE OF LIABILITY FOR MINORS

(For a Minor - Under the Age of 19)
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)
FIELD TRIP PERMISSION FORM
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 Museums

Dates of Trips: June 21 & June 28
Departure Time: 8:30am & 12:30pm
Return Time: 10:30am & 3:30pm

Complete this form with your preference

My Child,   First Name   Last Name   MAY participate in the above trips.

Signature of Parent or Guardian
Signature
Date

My Child,   First Name   Last Name  MAY NOT participate in the above trips.

Signature of Parent or Guardian
Signature
Date

The University reserves the right to cancel or change any or all field trips if necessary.
MEDICAL INFORMATION AND RELEASE FORM
Student’s Name*
Date of Birth*

MonthDayYear
Date
Age*
Place of Birth*
Family Doctor’s Name*
Telephone Number*
Name of Medical Insurance*
Group Number*
Please answer the following questions:
Is your child in good physical condition?*

YesNo
If no, please explain condition(s)
Does your child currently take any medication?*

YesNo
If yes, please list all medication names, dosage, frequency
Date of last physical?*

MonthDayYear
Date
Name of health care professional who performed last physical exam?*
Location where physical was done*
Special Needs: (check all that apply)

Hearing ImpairedSpecial DietVisually ImpairedPhysical DisabilityLearning DisabilityProsthesisOther: Explain
In case of a medical emergency, who should we contact?
Contact #1 Name*
Relationship*
Cell Number*
Please enter a valid phone number.
Work Number*
Please enter a valid phone number.
Contact #2 Name*
Relationship*
Cell Number*
Please enter a valid phone number.
Work Number*
Please enter a valid phone number.
Contact #3 Name*
Relationship*
Cell Number*
Please enter a valid phone number.
Work Number*
Please enter a valid phone number.
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.
Signature of Parent/Guardian*

Clear
Date*

MonthDayYear
Date
Signature of Student*

Clear
Date*

MonthDayYear
Date
IMAGE RELEASE FORM
The undersigned hereby understands and agrees to the following:
- All photographs are property of Alabama State University and may be used in any and all media, and for advertising or promotional use.
- The undersigned agrees that no payment of any kind will be earned from the usage of photographs.
- By signing this form, any cause of action pursuant to the use of subject photographs or names is hereby waived.
Student's Name*

First NameLast Name
Age*
Signature of Student*

Clear
Parent/Guardian's Number*
Please enter a valid phone number.
Name of Camp*
Signature of Parent/Guardian*

Clear
Please Upload a Copy of Your Photo ID*

Cancelof

Select your camp week(s) below:*

SKYCAP Reimagined (FULL DAY) Product Image

SKYCAP Reimagined (FULL DAY) GRADES K-6

$200.00

FULL DAY CAMP	Quantity	Price
Week 1: June 12-16		$200.00
Week 2: June 20-23		$200.00
Week 3: June 26-30		$200.00

Item subtotal:$0.00

Additional Camp T-ShirtOptional

$7.00 Quantity

Enter coupon

Total

$0.00

Payment Methods

Credit Card

Apple Pay

Google Pay

Payment must be received to secure your camper's registration.

Contact our office at 334-229-4686 for assistance with registration
915 S. Jackson Street | Montgomery, AL 36104 | 334-229-8487 | www.alasu.edu
Should be Empty:

Student’s Information

Parent/Guardian’s Information

SKYCAP Information:

RELEASE OF LIABILITY FOR MINORS

FIELD TRIP PERMISSION FORM

MEDICAL INFORMATION AND RELEASE FORM

IMAGE RELEASE FORM

Payment Methods

Payment must be received to secure your camper's registration.