TEXAS STATE UNIVERSITY

June 19-22

To begin your enrollment, please fill out the following form:

Seminar Type

Please select from the following:

Camper Status

Resident ($500)

Commuter ($400)

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Camper Phone

(###)

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Gender

Male

Female

T-Shirt Size

Roommate Preference

Please list the name(s) of anyone you wish to room with.

School Represented

Director Name

First Name

Last Name

Director Phone

(###)

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####

Director Email

Parent/Guardian Name

First Name

Last Name

Parent/Guardian Phone

(###)

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Parent/Guardian Email

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone

(###)

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Health Insurance Company

Policy #

Allergies

Restrictions

Consent and Responsibility Clause

General • Participants will be given a detailed list of site-specific guidelines and rules upon arrival at each University. • Participants are expected to follow all schedules and curfews. These will be strictly enforced. • Participants will be provided a name tag to be worn at all times when out of their room or on the campus. The nametag is to be clearly displayed. • Loud, boisterous, or unruly behavior will not be tolerated. The University and SASI reserve the right to define this standard of behavior. • Participants will be held financially liable for all damage that may occur as the result of their behavior or actions, intended or unintended. Campus Related • Participants are not leave the campus under any circumstances. • Participants are not allowed to leave their assigned room after curfew unless evacuated by event staff, local authorities, or university personnel. • Visiting of participants in the dorm or sleeping areas of the opposite sex will not be allowed at any time. • Participants are not to travel around the campus alone. Participants should travel in groups of at least 2 to all events. • Participants are not to allow people into any event or rooming area who are not camp participants or event staff. • Participants are not to reveal rooming assignments, phone numbers, etc. to persons or people who are not part of the event staff, their family, or event participants. Staff Related • Participants are expected to follow the directions and instructions of University and SASI staff at all times. • Participants are expected to be respectful of all University and SASI personnel and its agents, including but not limited to conference staff, at all times. Emergencies • Participants are expected to notify event staff or university police for any suspicious activities. • Participants are to contact 911 in an emergency situation, then University or SASI Staff. Recreation • Participant may swim only at designated times. Participants will be expected to follow all guidelines of safe practices for the swimming areas. • During designated “free time” and “social events” participants will not be allowed to visit with participants of the opposite sex in their rooms. Males in Male rooms and Females in Female rooms only. Students with disabilities may let the camp director know what accommodations are needed. I understand that SASI – The Leadership People, LLC and their respective officers, directors, agents (including Texas State University, The University of North Texas and The University of Houston and their respective directors, officers, employees and agents) and employees shall not be nor later become, liable or responsible in any way in conjunction with services, for any death, injury, damage, delay or irregularity which may occur while participating in this SASI sponsored event (the “Sponsored Event”). In case of emergency, I hereby give my consent for a qualified physician to perform any medical or surgical procedures s/he deems necessary to my welfare while participating in the Sponsored Event. It is understood that SASI and medical personnel will make every attempt to contact my emergency contact if I am unable to make determinations concerning my treatment. In the event they cannot be reached for an emergency, I hereby give permission to the physician selected by SASI to secure and administer such treatment(s) as may be necessary, including hospitalization. I also authorize SASI – The Leadership People, LLC and its agents to release copies of my medical record to hospitals and other physicians to which they are referred and to insurance companies for payment of the medical claim. A photocopy of is as valid as the original. Further, this authorization permits said physician to hospitalize, secure appropriate consultation, order injections, anesthesia (local, general or both) or surgery for me if such emergency conditions warrant. I hereby assume and agree to pay in indebtedness or physician’s or surgeon’s fees and hospital charges for such service, and for any ambulance or any other emergency transportation that may be needed. I hereby irrevocably grant to SASI – The Leadership People, LLC, and their respective agents, licensees and assigns, the right to use in any and all media and in any and all forms my name, likeness, photographic prints and any video or audio reproduction of sounds, performance or appearances of me while attending the Sponsored Event, for any purpose including promotion, advertising or otherwise. I understand I will not be paid any royalty or other compensation. With the use of the rights, I hereby release SASI – The Leadership People, LLC and its agents, licensees and assigns from all claims, liabilities and/or damages which now or in the future may arise from such use. I understand that consumption or possession of any alcohol is prohibited. I understand that a violation of this prohibition will result in the request for my departure from the residence halls.

Electronic Signature

By entering full name below I consent and agree to SASI – The Leadership People, LLC’s Terms and conditions. I also give my permission for the individual listed above to participate in the camp.

Parent Signature

First Name

Last Name

Student Signature

First Name

Last Name

TEXAS STATE UNIVERSITY

June 19-22

Inspire | Empower | Cultivate

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