2019 Lao Summer Camp Registration

STUDENT INFORMATION
Student Name *
Student Name
Student Date of Birth
Student Date of Birth
Student Gender *
PARENT/GUARDIAN INFORMATION
Parent/Guardian Name *
Parent/Guardian Name
Parent/Guardian Address *
Parent/Guardian Address
Parent/Guardian Home Number *
Parent/Guardian Home Number
Parent/Guardian Mobile Number
Parent/Guardian Mobile Number
EMERGENCY CONTACT
Must be other than parent/guardian listed
Emergency Contact Name *
Emergency Contact Name
Emergency Contact Home Number *
Emergency Contact Home Number
Emergency Contact Mobile Number
Emergency Contact Mobile Number
MEDICAL & PICK-UP INFORMATION
Clinic Phone Number
Clinic Phone Number
INSURANCE INFORMATION
Insurance Phone Number
Insurance Phone Number
PAYMENT
How Will You Be Paying? *
All tuition is due on the first day of camp. Please note, unpaid tuition fees will result in student(s) losing their spot in camp.
PERMISSION, CONSENT, MEDIA RELEASE
PERMISSION FORM I give permission for my child as listed in this registration to participate in the 2019 Lao Summer Camp presented by the Pom Foundation, in partnership with Wat Lao Mixayaram. I give my permission for the above named student to be treated by a medical professional as deemed necessary by Pom Foundation and its staff, and for them to secure my student’s medical, dental, surgical, x-rays, and anesthesia help as deemed necessary. I also give permission for Pom Foundation, Wat Mixay, and their representatives to provide supervision for my child during programs conducted at Wat Lao Mixayaram. I understand that such participation is voluntary. All conditions of the program have been explained to my satisfaction. CONSENT AND RELEASE I agree to release Pom Foundation, Wat Lao Mixayaram, and their representatives from all liability, loss, damage, costs, claims, or causes of action including, but not limited to, bodily injuries and property damage arising from participation in Pom Foundation and Wat Lao Mixayaram events, or any activities sponsored or organized by Pom Foundation and Wat Lao Mixayaram. I further agree to indemnify and hold harmless Pom Foundation, Wat Lao Mixayaram and their staff, organizers and agents from any and all liability, loss, damage, costs, claims, or causes of action, including attorney’s fees and witness costs, arising out of the undersigned‘s participation in this community summer camp. MEDIA RELEASE I hereby authorize Pom Foundation and Wat Lao Mixayaram to use my child’s picture for its public relations activities, which may include its newsletter, brochure, photo displays, and/or other organization and program promotional materials. I understand that I have the right to revoke this consent in writing, at any time, except to the extent that action has been taken in reliance upon this consent. I further understand that I have the right to request a restriction as to how the picture is used.