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Special Interest / Interactive Camps Registration

Registrant Name (required)
Gender
 Male Female
Age
T-Shirt

Contact Information

Guardian First Name
Guardian Last Name
Email (required)
Phone Number (required)
Alternate Phone Number
Address

City
State
Zip

Course Registration

Art Session
 Session 1 Session 2 Session 3 Session 4 Session 5 Session 6
Sports & Activities Session
 Session 1 Session 2 Session 3 Session 4 Session 5 Session 6 Session 7

Medical Information

Family Doctor

Is participant ALLERGIC TO ANY MEDICATIONS or environmental substances?
 Yes No

Is participant on any medications (PRESCRIPTION OR NON-PRESCRIPTION)?  Yes No

Does participant have any chronic illness (es) or physical problems?  Yes No

Health Issues:

**IF PRESCRIPTION OR NON-PRESCRIPTION MEDICATION MUST BE TAKEN DURING CAMP,
THE PARENTAL MEDICATION SELF-ADMINISTRATION CONSENT AND PHYSICIAN MEDICATION SELF-ADMINISTRATION CONSENT MUST BE COMPLETED AND RETURNED TO THE OFFICE OF CONTINUING EDUCATION, NO LATER THAN TWO (2) WEEKS PRIOR TO THE START OF CAMP.

I give the staff of Nicholls State University permission to administer emergency attention to my child. In the case of an emergency, campus police/personnel or ambulance services may escort my child to Thibodaux Regional Medical Center.

Photograph Consent

Nicholls State University occasionally photographs summer camp participants to post on the website. We are sending you this parental consent form to both inform you and to request permission for your child’s photo/image to be uploaded to the Nicholls State University website. Pictures are NEVER redistributed to any third party.

Release From Liability Form

I, the undersigned, being of full age of majority, hereby release Nicholls State University (hereinafter "Nicholls") and its agents from all claims that I may have against it, now and in the future, for any injury that I [or my minor child] may incur as a result of my [or my child's] participation in the following event(s) sponsored by Nicholls;
I understand fully and accept the risks that are inherent in the described activities including off-campus field trips. With full understanding of the risk involved, I waive my right [and my child's right], to sue Nicholls for any injury sustained through my own, [my child's] or Nicholls' negligence. I further agree to indemnify Nicholls and its agents for any damages that may be assessed against it or them in a court of law pursuant to any claim arising from the event(s) described above.

I accept all terms and conditions
Initial

To Pay with credit/debit card, please download the authorization form and fax it to 985-448-4552

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