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