This space for office use only:
2016 Camp Application
Camp Dates: June 12 – 17, 2016
Registration # ________
Date Recv’d: _____ / _____ / ______
Pmt Type: _____________________ Amount $ ___________
Input Date: ____________ Health Form Received: ❒
Registration confirmation and all other camp communication will ONLY be via the emails provided below.
about the camper:
First Name _________________________ Last __________________________
Nickname (for Nametag) ______________________________________________
Mailing Address: ____________________________________________________
City: ____________________________ State: _________ Zip: ______________
Student Email: ______________________________________________________
Home Phone: ___________________ Student Cell Phone: ___________________
Date of Birth ______ /______ / ______ Gender _______
M L
T-Shirt is INCLUDED in tuition. (Circle Size) S
XL
2X
How were you referred to Financial Planning Academy?:
❒ Poster/Ad ❒ Website ❒ Teacher/Counselor ❒ Professional
Referring Person: ____________________________________________
about the camper’s parent/guardian: (please list primary contact first)
PARENT/GUARDIAN 1: (primary contact)
First Name ________________________ Last Name _______________________
Mailing Address: ____________________________________________________
City: ___________________________ State: _________ Zip: ________________
Email: _____________________________________________________________
Home Phone:_______________________________________________________
Work Phone _________________________________________ ext. __________
Place of Business ____________________________________________________
Cell Phone: ________________________________________________________
PARENT/GUARDIAN 2:
First Name ________________________ Last Name _______________________
Mailing Address: ____________________________________________________
City: ___________________________ State: _________ Zip: ________________
Email: _____________________________________________________________
Home Phone:________________________________________________________
Work Phone _________________________________________ ext. ___________
Place of Business ____________________________________________________
Cell Phone: _________________________________________________________
In case of emergency and parent or guardian is unavailable, contact:
Name _____________________________________________________ Relationship to Camper ______________________________________________________
Day Phone _________________________________
Evening Phone ________________________________ Cell phone __________________________________
housing:
All students will be required to stay on-campus in Gordon Hall at Texas Tech
University.
Roommate Preference __________________________________________________
special accommodations:
Do you require any special assistance? ____________________________________
____________________________________________________________________
Do you have any dietary restrictions?
If your preference is not available, do you wish to be placed with someone from your _____________________________________________________________________
school (if possible)? ❒YES ❒ NO
Financial Planning Academy | 1301 Akron Ave, Room 260 | Lubbock, TX 79409 | financialplanningacademy.hs.ttu.edu | pfp@ttu.edu
Financial Planning Academy Application, Page 2
Student Name (Last, First):_________________________________________________
payment information:
Students selected to attend the camp will be charged $150 (includes lodging, meals, and program materials). Payment must be received within three weeks of
being selected to attend Financial Planning Academy. Limited funding is available to off-set the costs of Financial Planning Academy for students with financial
hardship. This funding can potentially be applied to the $150 registration fee (reducing registration to $50) and/or the cost of travel to and from the camp. If you
wish to seek funding for these items, you will be required to complete a short application that will be provided upon acceptance to Financial Planning Academy.
❒ I plan to apply for hardship funding
❒ I will pay the registration fee (or make arrangements for hardship funding with the camp staff) within three weeks of receiving notice of acceptance into
Financial Planning Academy.
Be sure to include all of the following with your application packet upon sending it in.
❒ Completed Application
❒ Completed Medical Information Form
❒ Copy of health insurance card (front and back) enclosed
❒ Parental Consent and Liability Release Form
❒ Student Questionnaire
❒ Parent & Student Signatures
❒ Photo/Testimonial Release Form
To submit your application packet, you can email it to pfp@ttu.edu (including all pages with signatures), or you can mail it to the address below.
Financial Planning Academy
Texas Tech University PFP
1301 Akron Ave, Room 260
Lubbock, TX 79409
Financial Planning Academy | 1301 Akron Ave, Room 260 | Lubbock, TX 79409 | financialplanningacademy.hs.ttu.edu | pfp@ttu.edu
Student Questionnaire
List any involvement in organizations and/or community service:
Activity
List any honors and/or awards:
Activity
Position Held
Years of Service
Position Held
Years of Service
If your involvement is limited, please explain why.
Why would you like to attend Financial Planning Academy?
What experience or skills do you offer to a team?
What do you hope to gain from attending Financial Planning Academy?
Additionally, please attach a resume if you have it.
Medical Information Form
Participant’s First and Last Name:
Student’s Primary Contact Number: (_____) ______-________
Sex: ______
Age: ______
Person to Notify in Case of Emergency:
Name: ___________________________________________
Relationship: _____________________
Home Phone Number: (_____) ______-________
Work Phone Number: (_____) ______-________
Cell Phone Number: (_____) ______-________
Current Prescription Medication (optional):
First Medication: ____________________________________ Amount: __________ Time: __________
Date Prescribed: _____/_____/______
Second Medication: __________________________________ Amount: __________ Time: __________
Date Prescribed: _____/_____/______
Third Medication: ____________________________________ Amount: __________ Time: __________
Date Prescribed: _____/_____/______
Do you have any of the following medical conditions?
Dietary restrictions:
Yes
No
Heart disease/high blood pressure
Seizures/epilepsy
Concussion or serious head injury
Heat exhaustion/stroke
Contact lenses/eyeglasses
If yes, please list: _____________________________________
Yes
No
Chest pain or fainting spells Yes
No
Yes
No
Diabetes
Yes
No
Yes
No
Major surgery/serious illness Yes
No
Yes
No
Asthma
Yes
No
Yes
No
Hearing Aid/hearing loss
Yes
No
Date of last tetanus shot: ___________________________________________________
Allergic to the following:
Medicines: ___________________________________________________________________________
Foods: ______________________________________________________________________________
Insect sting/bite: ______________________________________________________________________
Participant’s Signature: __________________________________________ Date: _________
Parent/Guardian Signature: ______________________________________ Date: _________
*NOTE – Please make sure to include a photo copy or scan of the student’s medical
insurance card with this form. If the student doesn’t have medical insurance, please
indicate that by circling ‘No Insurance’ below.
No Insurance
financialplanningacademy.hs.ttu.edu
pfp@ttu.edu
Parental Consent and
Liability Release Form
Students Name:____________________________________________________________________________
Last
First
MI
Parent/Guardian:___________________________________________________________________________
Last
First
MI
I understand participation in the Texas Tech University (the “University”) Financial Planning Academy
(“Program”) is completely voluntary. In consideration for the opportunity to participate in the Program, I, for
my child, myself, my executors, administrators, heirs and assigns, agree forever to indemnify and hold
harmless the University, the Charles Schwab Foundation (the “Foundation”), and their respective affiliates,
officers, directors, employees, agents, and volunteers, as well as all entities and personnel (including
consultants) supervising, participating in, sponsoring, or associated in any manner with the Program from
any and all claims (including, but not limited to, property loss, claims of damages, liabilities, injury,
expense, or loss occurring from activities or travel associated with the Program, as well as attorney’s fees
incurred in defense of such claims).
I believe my child is mentally and physically capable of participating in the Program, and I understand and
assume any risks involved in said participation. I understand that there may not be medical personnel
available on staff for the Program. In case of any accident or need of emergency medical attention, I give
permission and authorize Financial Planning Academy staff to: (1) administer emergency first aid care and
treatment at the scene of an emergency, and/or (2) take my child to a doctor and/or emergency facility of
their choice. It is understood that all expenses for treatment provided will be borne by the parent,
guardian, or child.
Furthermore, I give my permission for my child to travel with the staff and other participants to and from
the official events of the Program.
My permission is granted to the Financial Planning Academy, its agents, or employees to photograph,
record, film, and videotape my child for future promotion of the Program. I agree that all negatives and
positives, whether prints, video, film or data file, are the property solely of Financial Planning Academy, or
the individual or entity designated by it for use as it deems appropriate to market and promote the
Program.
I HAVE CAREFULLY READ THIS ENTIRE RELEASE, WAIVER OF LIABILITY, EMERGENCY MEDICAL
AUTHORIZATION, AND CONSENT FORM AND I FULLY UNDERSTAND ITS CONTENTS. I HAVE SIGNED THIS
FORM OF MY OWN FREE WILL. I AGREE TO BE LEGALLY BOUND BY IT.
I understand that by signing this Parental Consent form, I am authorized and have legal authority to
consent on behalf of the above-named minor child.
_________________________________________________________________ ___________________
Parent/Guardian Signature
Date
PHOTO/TESTIMONIAL RELEASE FORM
PERMISSION TO USE IMAGE/TESTIMONIAL DATA
I, ________________________________, give Texas Tech University and/or Texas Tech
University System (herein, “Texas Tech”), its employees, designees, agents, independent
contractors, legal representatives, successors and assigns, and all persons or departments for
whom or through whom it is acting, the absolute right and unrestricted permission to take, use
my name, testimonial and biographical data and/or publish, reproduce, edit, exhibit, project,
display and/or copyright photographic images or pictures of me or my child(ren), whether still,
single, multiple, or moving, or in which I (they) may be included in whole or in part, in color or
otherwise, through any form of media (print, digital, electronic, broadcast or otherwise) at any
campus or elsewhere, for art, advertising, recruitment, marketing, fund raising, publicity,
archival or any other lawful purpose.
I waive any right that I may have to inspect and approve the finished product that may be used or
to which it may be applied now and/or in the future, whether that use is known to me or my
child(ren) or unknown, and I waive any right to royalties or other compensation arising from or
related to the use of the image or product.
I release and agree to hold harmless Texas Tech, its Board of Regents, officers, employees,
faculty, agents, nominees, departments, and/or others for whom or by whom Texas Tech is
acting, of and from any liability by virtue of taking of the pictures or using the
testimonial/biographical data, in any processing tending towards the completion of the finished
product, and/or any use whatsoever of such pictures or products, whether intentional or
otherwise.
I certify that I am at least 18 years of age (or if under 18 years of age, that I am joined herein by
my parent or legal guardian) and that this release is signed voluntarily, under no duress, and
without expectation of compensation in any form now or in the future.
_____________________________________
Name (Please print)
_____________________________________
Signature
_____________________________________
Date
___________________________________
Signature of parent or legal guardian if
under 18 years of age