General Registration/Application Closed Friday, April 28, 2017
Students, please answer below:
Person(s) other than parent/ guardian authorized to pick up and drop off child
Emergency Contact Information
Authorization for consent to medical treatment
Any individual under the age of 18 years without a complete Consent to Medical Treatment form on file prior to the start of camp will not be able to participate in any camp activity. The directors and staff are not responsible for any medical, dental or other expenses resulting from accidents.
The undersigned parent/ Guardian of FAMA Camp Participant, hereby authorize the FAMA Summer Camp staff to consent to any diagnostic procedure (including x rays), to the administration of any medical or surgical treatment, or to any hospital care when any, or all are rendered under the general supervision of any physician and or surgeon licensed under the provisions of the Medical Practice Act. My child is in good health and I know of no medical reason why he/she cannot participate in any camp activities.
The authorization is given in advance of any specific diagnosis, treatment or medical care being required.
Allergy and Medication Form
This form must include all medications (over the counter and prescription) that a student is allowed to have in their possession during FAMA Summer Camp.
My student has my permission to possess and take the above medication as described above while attending FAMA Summer Camp on the Centro Cultural Hispano de San Marcos Campus.
Photo/Video Release Form
I give Texas State University and/or the Texas State University System (herein"Texas State"), its employees, designees, agents, independent contractors. legal representatives, successors and assigns, and all persons or departments for whom or through whom it is acting, the absolute right and unrestricted permission to take, use my name, testimonial and biographical data and/or publish, reproduce, edit, exhibit, project, display and/or copyright photographic images, pictures or videos of me or my child(ren), whether still, single, any form of media (print, digital, electronic, broadcast or otherwise) at any campus or elsewhere, for art, advertising, recruitment, marketing, fund raising, publicity, archival or any other lawful purpose.
I waive any right that I may have to inspect and approve the finished product that may be used or to which it may be applied now and/or in the future, whether that use is known to me or my child(ren) or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the image or product.
I release and agree to hold harmless/liable Texas State, its Board of regents, officers, employees, faculty, agent, nominees, departments, and/or others for whom or by whom Texas State is acting, of and from any liability by virtue of taking of the pictures or using the testimonial/biographical data, in any processing tending towards the completion of finished product, and/or any use whatsoever of such pictures or products, whether intentional or otherwise.
I certify that I am 18 years of age (or if under 18 years of age, that I am joined herein by my parent or legal guardian) and that this release is signed voluntarily, under no duress, and without expectation of compensation in any form or in the future.
By filling out this information you are consenting to participate in the research efforts of this program. If you have any questions about research participation you can contact Dr. Laura Rodriguez at firstname.lastname@example.org