Summer Game Design Camps Registration Form (Page 2 of 3) in pdf

740.351.3390 |

740.351.3018

Phone

Fax

940 Second Street | Portsmouth, OH 45662

PARENTAL CONSENT AND RELEASE: SUMMER GAME DESIGN CAMPS 2016

Child’s First Name _______________________________________ MI__________ Last Name___________________________________________________ Age_________

The undersigned, as parent or guardian of the child named above, consents that my child participate in Shawnee State University’s program, Gaming Day Camps. I acknowledge that the child named is a

minor under the age of 18.

I acknowledge that the Program includes indoor and outdoor activities of the nature that may expose the child to hazards or risks that may result in illness, personal injury or death. I

understand and appreciate the nature of such hazards and risks.

Although a minor, my child is aware of the risks involved in participating in the program. I assure Shawnee State University that I have carefully counseled my child on the risk of participating. Further, I

assure Shawnee State University that there are no physical or other reasons that preclude my child from participating in the program.

I agree that all requirements, directions and standards set by Program staff, use of any equipment or supplies under the supervision of the staff, shall be deemed to have been accomplished for the benefit

of my child.

I hereby release and discharge Shawnee State University, its board of Trustees, officers, employees and agents associated or connected with the Program from every claim, liability or damage of any kind

that may result from my child’s participation in the Program.

Parent/Guardian’s Printed Name _________________________________________________________________________________ Date___________________________

Signature ________________________________________________________________________________________________________________________________

740.351.3390 |

740.351.3018

Phone

Fax

940 Second Street | Portsmouth, OH 45662

PHOTO AND MEDIA RELEASE: SUMMER GAME DESIGN CAMPS 2016

By submitting this form, I the undersigned, grant permission to Shawnee State University (SSU) and/or the Shawnee State University Development Foundation (SSUDF) to publish my story and/or likeness

and/or picture for use in promotional, educational, display or other media publications including newspapers, magazines, television, brochures, pamphlets, instructional material, books, web pages and/or

other educational or promotional material.

I hereby grant SSU and/or SSUDF permission to interview me and/or to use my likeness in photograph(s)/video in any and all of its publications and in any and all other media, whether now known or

hereafter existing, controlled by SSU and/or SSUDF, in perpetuity, and for other use by the SSU and/or SSUDF. I will make no monetary or other claim against SSU or SSUDF for the use of the interview and/or

the photograph(s)/video.

Child’s First Name _______________________________________ MI__________ Last Name___________________________________________________ Age_________

Year in School (freshman – senior) ____________________________________________ School_______________________________________________________________

Home Address ___________________________________________________________ City________________________________ State________________Zip_________

Cell Phone ________________________________________________________ Home Phone_______________________________________________________________

Parent/Guardian’s Printed Name _________________________________________________________________________________ Date___________________________

Parent/Guardian’s Signature __________________________________________________________________________________________________________________

Summer Game Design Camps Registration Form Page 2

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