2015 Digital Media Camp Registration, Waiver and Release

The 2015 Digital Media Camp will be held May 26, 27, and 28 from 8am to 3pm in TC room 013 on the
NSU campus. Participants need to pack a lunch for May 26th and 27th, a pizza lunch will be provided May
28th. Parents, guardians, and others are welcome to come to a special showcase of student media projects
that will be held at the end of the camp, May 28th at 3pm in TC room 013 (downstairs in the TC building).
Participants must be able to use a mouse and keyboard and know how to open and use simple
computer applications. To register your son or daughter for the 2015 Digital Media Camp, Fill out the
information on this form, sign, and submit it to Dr. Gregory Francom (gregory.francom@northern.edu) in
the school of education (school of education secretary Jackie Blide will place it in my box). Also include
$30 for the camp fee (the money goes to facilities, equipment, food and NSU student counselor(s)). Make
checks payable to Northern State University or NSU. In order to give participants the best attention
and digital media instruction, only the first 15 participants will be able to come. Sign up by May 19th!

I, on behalf of myself, my personal representatives and my heirs, hereby voluntarily agree to release, waive, discharge, hold
harmless, defend, and indemnify NSU and its faculty, agents, officers and employees from any and all claims, actions or losses
for bodily injury, property damage, wrongful death, loss of services, or other occurrences which may be a result of my childs
participation in the 2015 Digital Media Camp. I specifically understand that I am releasing, discharging and waiving any claims
or actions that I may have presently or in the future for the negligent acts or other conduct by the faculty, agents, officers or
employees of NSU.
I also consent to allow the use of voice, video, image or likeness in photographs and/or video of my child or my childs work on
the Digital Media Camp Website, textbooks, and other social media websites such as facebook and youtube.
MEDICAL PERMISSION AUTHORIZATION
If the participant is of minority age, the undersigned parent or guardian hereby gives permission for NSU to authorize emergency
medical treatment as may be deemed necessary for the child named below while participating in the 2015 Digital Media Camp.
I HAVE READ THE ABOVE WAIVER AND RELEASE AND BY SIGNING IT AGREE IT IS MY INTENTION TO EXEMPT
AND RELIEVE NSU FROM LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH
CAUSED BY NEGLIGENCE OR ANY OTHER CAUSE.

Print Parent/Guardian Name

Parent/Guardian Signature

Date

Print Full Name of Participant

Participant Age

Participant Date of Birth

Address

City, State, Zip

Participant Grade (Must be 4th

through 7th grade)

Parent/Guardian Email

Parent/Guardian Phone