2018 Summer Camp Admission Form July 22-28

2018 TTU Academic Summer Camp Admission Form

July 22-28, 2018

Form Instructions:Please fill out the form in ALL CAPITAL LETTERS. The red asterisk * means that information is required. After submitting the form, you will see a message that says, "Thank you for completing the form." This message means your form was successfully submitted. If you do not receive this message, please fill out the form and submit again.

Full Legal Name of Participant*

Preferred First & Last Name (This is for your ID and class rosters)*

First NameLast Name

Birth Date*

MonthDayYear

Current Grade*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Full Name of Parent, Managing Conservator, or Guardian *

Person of Contact in Brazil Full Name*

E-mail Address*

Home Phone*

Country CodeArea CodePhone Number

Cell Phone*

Country CodeArea CodePhone Number

Work Phone*

Country CodeArea CodePhone Number

Have you participated in any of our programs before?*

YesNo

Where did you hear about our program?*

Do you have a roommate request?Your roommate must also request to room with you. Your preference will be considered, however, not guaranteed.

Roommate Requested Preferred First & Last Name*

First NameLast Name

Course Selections

Select first and second choice for morning and afternoon courses.

Morning ClassFirst Choice*

Morning ClassSecond Choice*

Afternoon ClassFirst Choice*

Afternoon ClassSecond Choice*

Medical Conditions or Allergies

Please list any medical conditions or allergies.

Air Travel InformationTTU personnel will pick participants at the ARRIVALS lounge and accompany them to and from campus.

Example: JUL 4 - JJ 3189 - FOZ>GIG 3:15PM-5:13PMJUL 4 - AA 0904 - GIG>MIA 08:05PM-04:00AMJUL 5 - AA 0675 - MIA>DALLAS FORT WOR 06:25-08:25 AMJUL 5 - AA 2103 - DALLAS FORT WOR>LUBBOCK INTL 09:20-10:25AM

Arrival in Lubbock July 22, 2018 Lubbock (Lubbock Preston Smith International Airport)*

Departure from Lubbock July 28, 2018 Lubbock (Preston Smith International Airport)*

Upload scanned files

Files must be JPG, PDF, BMP or PNG format. The file size limit is 5 MB.

Photo (3X4 or Passport)*

Select File

Passport ID Page(s)*

Select File

Formulário da Policía Federal preenchido autorizando o menor a viajar desacompanhado (Brazilian FBI form for parents to authorize their kids to travel alone)*

Select File

US VISA Page(s)*

Select File

Brazilian Birth Certificate or RG*

Select File

International Health Insurance Page(s) (Copy of medical health insurance card)*

Select File

Consent to Medical Treatment, Media Coverage, and Release & Hold Harmless Agreement

I, the Parent, Managing Conservator, or Guardian of the Participant, as stated above, confirm that he/she will be part of the Texas Tech University Summer Camp from July 22-July 28, 2018, a program for students sponsored by Texas Tech University. I hereby affirm that I desire to have my minor child to ride public transportation or in vehicles driven by Texas Tech employees or representatives to and from designated activities. I, the undersigned, am aware of the dangers associated with travel by motor vehicle or other conveyance and the possibility of injuries or death while in transit. I understand that my minor child will participate in general classroom, educational, 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 minor child to attend the activities mentioned in this document, I, the undersigned, do hereby release, indemnify, and hold harmless Texas Tech University, its Board of Regents, all the University’s officers, agents, and employees, and the Institute for Development and Enrichment of Advanced Leaners 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, employees, officers, members, or any other person or participant in said activities or while in transit to and from activities.
I hereby consent to any and all emergency medical treatment needed by said Minor Child as administered by a clinic or attending physician and accept responsibility for full payment and said treatment. I give my permission for this document to be photocopied for medical personnel.

I hereby give permission for the name minor listed above 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 and/or any future related programs. 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 publicizing and promoting the program(s).

The terms hereof shall also serve as a release and an assumption of risk for my minor child’s heirs, executor and administrator, and for all members of my child’s family and be pleased as a bar of litigation.

Jurisdiction of this matter and venue shall lie in Lubbock, Lubbock County, Texas. I, the undersigned, on behalf of my minor child agree to indemnify and hold Texas Tech University, its Board of Regents, and all the University’s officers, agents and employees (18) years and read this Release and Hold Harmless Agreement and voluntarily understand and accept its terms.

Check to agree*

Agree

Signature of Parent, Managing Conservator, or Guardian:*

By filling out the above field you are agreeing to the terms outlined above.

Today's Date*

MonthDayYear