Summer Camp Detailed Registration Form

Student's Name*

First NameLast Name

Birth Date*

MonthDayYear

Gender*

MaleFemale

Phone Number*

Area codePhone Number

Email*

example@example.com

Level of Education*

DiplomaBachelor DegreeMasters DegreeDoctoral Degree

Name of College/University:*

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Information

Emergency Contact's Name*

First NameLast Name

Relationship

Phone Number*

Area CodePhone Number

Alt. Phone Number*

Area CodePhone Number

Do you have any allergies (food/medications), chronic illness, or medical conditions? If yes, please describe in detail.*

Is the student on prescribed medication? If yes, please explain any instructions.*

IMPORTANT: Medical Insurance Requirement

All participants MUST have a valid medical insurance coverage for the duration of the summer camp. This insurance should cover any potential medical expenses that may arise due to illness or injury during camp activities.

Before you can attend camp, please ensure that:

You are covered by a current medical insurance policy.
Provide a copy of the insurance card (front and back) with your registration materials.
Complete and return the Medical Insurance Verification Form, which includes your insurance provider’s name, policy number, and emergency contact information.

These documents should be submitted together with payment proof and details of boarding upon approval by the Secretariat.

Informed Consent and Acknowledgement

I hereby will participate in any and all activities prepared by Faculty of Health Sciences, Universiti Teknologi MARA during the selected camp. I acknowledge that I expected to follow the camp’s rules and guidelines to ensure a positive and safe experience for all participants. In exchange for the acceptance of my candidacy by Faculty of Health Sciences, Universiti Teknologi MARA, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Faculty of Health Sciences, Universiti Teknologi MARA and all its respective officers, agents, and representatives from any and all liability for injuries to me arising out of traveling to, participating in, or returning from selected camp sessions.

In case of injury that may happen, I hereby waive all claims against Faculty of Health Sciences, Universiti Teknologi MARA, including the staffs and affiliates, all participants, sponsoring agencies, and, if applicable, owners and lessors of premises used to conduct the event. I understand that there is a risk of being injured that is inherent in all outdoor activities. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

I hereby release, waive, and discharge Faculty of Health Sciences, Universiti Teknologi MARA, its staff, and volunteers from any and all liability, claims, demands, or causes of action that may arise from my participation in the summer camp, except in cases of gross negligence or intentional misconduct.

Medical Release and Authorization

The parent and/or Guardian of the named student has permitted the participation of the named student, and therefore, hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the student, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to the Faculty of Health Sciences, Universiti Teknologi MARA and its affiliates including Deans, Lecturers, and Secretariat committee to provide the needed emergency treatment prior to the child’s admission to the medical facility.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named student, in the absence of parent/guardian.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Date

Signature*

Summer Camp Registration

Student Information