Physics Camp for Fort Worth ISD

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APPLICATION INSTRUCTIONS

This is an application for camp registration. In most cases, if the following qualifications are met, notification will be received within one week of receipt of all documents. If you do not fit the following description, you may still apply for the camp, however we encourage you to apply for the open enrollment camp at UTD (7/8 - 7/19). If we have not met our registration goals by 5/1/2019, then we may allow non-qualifying female students to be enrolled in this camp. 

WHO IS THIS CAMP FOR? 
  • Female students who will be taking their first physics course in the fall of 2019
  • Registered students at the hosting district
  • Students who can attend the majority of the camp days
INSTRUCTIONS
In order to complete this form and submit you must have the following: 
  • Student contact information
  • Student math and science course history
  • Parent/Guardian contact information
  • Student Allergies and Medical information
  • (Optional) Essay for application to earn a TI graphing calculator: Explain two or more ways in which earning a TI graphing calculator would support your educational goals. Response must be at least a full paragraph with complete sentences.
Additional Notes:
  • Items marked with a red asterisk are required.
  • There are multiple pages of this form.
  • Please click through to the final page and hit "Review and Sign" button for your information to be saved.
  • You will then be asked for a guardian's digital signature.  After submission, you will then receive a verification email. 
  • You must confirm that you received the verification email before the digitally signed response and application for registration can be finalized.

STUDENT INFORMATION

MEDICAL INFORMATION

In case of emergency, we will attempt to contact the guardian. In the event that treatment for the child is deemed necessary under the circumstances without a guardian present, we need to have the student's medical information. Medical insurance is not required for participation. If the student does not have medical insurance, you may leave the fields blank. 

PARENT/GUARDIAN INFORMATION

APPLY TO EARN A TI GRAPHING CALCULATOR

Students who attend all 10 days of camp are qualified to earn a TI Graphing Calculator, valued at ~$130-150. If the student is interested in earning this attendance reward, the student must respond to the following prompt. 

COST of CAMP

The average cost of the two-week camp is $650 per student. Because of generous donors and received grants, we are able to offer the majority of our camps at no-cost to the participants including the camp to which you are applying.

If your family is able to make a contribution so that another student can attend an empowering and inspiring STEM camp, would you consider making a tax-deductible donation?  Give today, and directly support young women’s success in STEM! 


Design Connect Create is a 501(c)3 organization. Donations are tax-deductible. You can make a donation at any time at designconnectcreate.org/give.

DCC CONSENT

DESIGN CONNECT CREATE SUMMER CAMP PARTICIPATION AGREEMENT AND RELEASE OF LIABILITY

I, the parent or legal guardian of student registrant ("Participant"), give my permission for my child to participate in the summer physics camp program (“Activity”) offered by Design Connect Create (“DCC”) and I acknowledge and agree as follows: 

I acknowledge and accept that the nature of the Activity could possibly expose my child to known and unknown risks, including, but not necessarily limited to, the danger of damage, injury or loss, such as property (personal or real) damage, illness, mental anguish, emotional distress, personal/bodily injury or death and I understand and appreciate the nature of such risks. My child is in sufficient physical and mental health to participate in the Activity and does not have any physical or mental conditions that could affect their ability to participate in the Activity. I have medical insurance coverage appropriate for my child’s participation in the Activity and have provided evidence of such insurance coverage and emergency contact information in this registration (page 3). 

I grant DCC and their representatives full authority to take whatever actions they may consider to be warranted under any circumstances regarding the protection of Participant’s health and safety. I understand that if my child requires medical treatment while participating in the Activity, an attempt will be made to call me once. In the event that I cannot be reached, I consent to such treatment for my child as may be deemed necessary under the circumstances. 

I understand that my child is expected to: 
  • (a) act and speak positively, and be courteous to all students and staff
  • (b) wear shorts at least fingertip length
  • (c) not wear midriffs
  • (d) remain on campus for the duration of the camp day (no leaving for lunch or breaks)
  • (e) ride the provided bus to field trips
I will notify the teacher or camp director of any absences or appointments prior to the first day of camp. If my child’s participation in the Activity is at any time deemed detrimental to the Activity or its other participants, as determined by the Activity’s organizers in their sole discretion, I understand that they may be expelled from the Activity without DCC or the organizers incurring any liability. 

I grant DCC permission to collect information via pre-camp and post-camp surveys to measure the impact of the Activity. DCC will not share any personal data or the identity of participant’s comments. All survey data will be reported only in aggregate format. 

I grant DCC the irrevocable right to use my child’s image, voice and name in photographs and video and audio recordings of the Activity. I understand that this use includes publication and distribution in printed, electronic and digital media, including, but not limited to, DCC materials and brochures, video and television broadcasts, and website, social media and online communications. I also understand that my child shall not receive any compensation in connection with this release. 

I knowingly and voluntarily hereby accept and assume all risk to my child that may arise from, relate to or result from participation in the Activity without limitation, all adjunct activities. I knowingly waive, acquit, release and forever discharge and covenant not to sue and shall indemnify, defend and hold harmless DCC, their respective directors, officers, employees, independent contractors, agents and representatives (collectively, the “Released Parties”) from any and all losses, liabilities, claims, damages, penalties, fines, judgments, awards, settlements, costs, fees and expenses (collectively, the “Losses”) that directly or indirectly, arise from, relate to or result from my child’s participation in the Activity including, without limitation, (a) any and all illness, mental anguish, emotional distress or injury to Participant’s person, including his or her death, (b) damage to Participant’s real or personal property and (c) any Losses caused in whole or in part by negligence or strict liability of the Released Parties. 

This Agreement constitutes the entire agreement and shall be governed by the laws of the State of Texas. If any provision of this Agreement is held unenforceable, this will not affect any other provision and this Agreement shall be construed as if the unenforceable provision had not been incorporated in this Agreement. 

I (i) have read and fully understand this Agreement and (ii) intend that this Agreement be legally binding and enforceable upon me and my family, estate, heirs and legal representatives.
You will be asked for a digital signature at the end of this registration. You will then receive a verification email.You must confirm that you received this verification email before the signed response and registration can be finalized.

FIELD TRIP CONSENT

FIELD TRIP VOLUNTARY RELEASE, ACKNOWLEDGMENT, ACCEPTANCE OF RISKS, AND INDEMNITY AGREEMENT FOR MINOR CHILD

Each two week physics camp normally takes field trips on both Friday's of camp. Most of the companies we visit require a separate release of liability. This page is a generic release that we will provide to the hosting company. It is possible that they may ask for a more customized form to be completed prior to camp. If this is the case, we will contact you. 
I, the undersigned parent or legal guardian of the named Participant, who is under 18 years of age, in consideration of the Participant being permitted to enter upon the property of a DCC Field Trip Hosting Company which will vary by camp (collectively, “Company”) and tour its facilities (the “Activity”), sponsored by Design Connect Create (“DCC”), hereby acknowledge, agree, promise and covenant with Company, its elected and/or appointed officers, directors, agents, and employees, and on behalf of myself, the Participant, our heirs, assigns, personal representatives and state as follows: 

CONSENT TO PARTICIPATE: I CONSENT to the Participant’s voluntary participation in the Activity. I give permission for the Participant to engage in activities at Company that include, but are in no way limited to, traveling between and touring Company’s facilities. 

ACKNOWLEDGMENT AND ACCEPTANCE OF RISKS AND RESPONSIBILITIES: I UNDERSTAND AND ACKNOWLEDGE that due to the nature of the work performed at Company’s facilities, participation in the Activity carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries. I UNDERSTAND AND ACKNOWLEDGE that these inherent risks range from minor bodily injuries to major bodily injuries, including catastrophic injuries such as death, as well as damage to personal property. I expressly agree to accept and assume all responsibility and risks arising from the Participant’s participation in the Activity. The Participant’s participation in this Activity is purely voluntary; no one is forcing the Participant to participate in spite of the known and unknown risks. 

I FURTHER UNDERSTAND AND ACKNOWLEDGE that during the time the Participant is on Company’s premises, DCC, not Company, is responsible for Participant’s supervision. 

RELEASE: I VOLUNTARILY RELEASE AND FOREVER DISCHARGE AND COVENANT NOT TO SUE COMPANY AND ALL OTHER PERSONS OR ENTITIES AFFILIATED WITH THEM, FROM ANY AND ALL LIABILITY, CLAIMS, DEMANDS, ACTIONS OR RIGHT OF ACTION, WHICH ARE RELATED TO, ARISE OUT OF OR ARE IN ANY WAY CONNECTED WITH THE PARTICIPANT’S PARTICIPATION IN THE ACTIVITY, INCLUDING BUT NOT SPECIFICALLY LIMITED TO THE NEGLIGENCE OF COMPANY, ITS OFFICERS, EMPLOYEES, AGENTS, AND AFFILIATES RESULTING IN ACCIDENTS, PERSONAL INJURY (INCLUDING DEATH), AND PROPERTY LOSS ARISING FROM, BUT NOT LIMITED TO, PARTICIPANT’S PARTICIPATION IN THE ACTIVITY. 

I AGREE, PROMISE AND COVENANT TO INDEMNIFY, DEFEND AND HOLD Company HARMLESS, and all other persons or entities affiliated with them, from all defense costs, including attorneys’ fees, or from any other costs incurred in connection with claims for bodily injury or property damage which the Participant may negligently or intentionally cause to third parties in the course of the Participant’s participation in the Activity. 

PHOTOGRAPH CONSENT: I hereby grant permission to Company and its representatives to record, use, and distribute audio recordings, photographs and/or digital images of my child for use in Company’s internal communications and promotion efforts, which may include inclusion in printed publications or materials, electronic publications, and/or internal Company Web sites. I agree that my child’s name and identity may be revealed in descriptive text or commentary in connection with the image(s). I authorize the use of these images without compensation to me or my child and release Company from liability for any violation of any personal or proprietary right I may have in connection with such use. All negatives, prints, digital reproductions and recordings shall be and remain the property of Company. 

ACKNOWLEDGMENT OF EFFECT OF THIS RELEASE AGREEMENT: I UNDERSTAND AND ACKNOWLEDGE that by signing this document I have given up certain legal rights and/or possible claims which I might otherwise assert or maintain against Company, its officers, employees, agents, and affiliates including specifically, but not limited to, rights arising from or claims for the acts or omissions, fault, negligence of Company, its officers, employees, agents, and affiliates. 

I UNDERSTAND AND ACKNOWLEDGE that the terms, herein are contractual and not a mere recital, and that I have signed this document of my own free act.

AGREEMENT: 

I UNDERSTAND that this is the entire Agreement with Company, its agents or employees, and that it cannot be modified or changed in any way by the representations or statements of DCC, or any volunteer, employee or agent of DCC, or by me without agreement by Company. I acknowledge that I am signing the agreement freely and voluntarily, and intend by my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law. 

MY SIGNATURE INDICATES THAT I HAVE READ THIS ENTIRE DOCUMENT, UNDERSTAND IT COMPLETELY, AND AGREE TO BE BOUND BY ITS TERMS.