49er Camp Registration, CSULB

Session 1: 6/17-7/12	Session 1
Session 2: 7/15-8/9	Session 2

Child First Name *
Child Last Name *
Address *
City *
State *
Zip Code *
Gender *	Male Female Prefer Not to State
Age *
Date of Birth *
School Grade in Fall 2024 *
School Name *
T-Shirt Size *
Medical and Behavioral Concerns (Include an Individualized Education Program (IEP) if relevant)	I will provide I.E.P.
Additional Notes

Parent/Guardian 1 Name *
Email *
Daytime Phone *

Parent/Guardian 2 Name
Email
Daytime Phone
Other than parents/guardians listed above, provide any additional people you are authorizing to pick up your child. In parenthesis next to name, include relationship to child. (i.e. Jane Smith (Grandma)).
Additional Designated Pick-up Person Names

I do hereby grant permission to the California State University, Long Beach Research Foundation (re-ferred to as “Camp/Research Foundation”) to photograph/video and to publish the said photograph(s)/video(s) of me and/or my Child(ren) on the Program/Research Foundation website and in related Program/ ResearchFoundation promotional brochures, advertisements and videos for the purpose of promoting the Program/Re-search Foundation’s business worldwide. I hereby waive all rights of privacy and/or compensation for me and my Child(ren), which I, or she/he, may have in connection with the use of my, or her/his, photograph, likeness, depiction or story, or any or all of them, in or in connection with said Program/Research Foundation websites, still photography, or video/film and any use to which the same or any material therein may be put, applied or adapted by the Program/Research Foundation in connection with the promotion of the Program/Research Foundation. I hereby grant the Program/Research Foundation permission to edit, crop, or retouch such photographs, andwaive any right to inspect the final photographs.

I, for myself and my Child(ren) and our respective heirs, administrators, successors and assigns hereby release the Program, the California State University, Long Beach Research Foundation, the State of California, Trustees of the California State University, California State University, Long Beach, and all officers, employees, volunteers and agents of each of them from and against any and all claims, liabilities, losses, expenses, causes of action, costs of every nature and/or damages of any kind (including, but not limited to, invasion of privacy, defamation, false light or misappropriation of name, likeness or image, unauthorized republication of image) arising out of, or in connection with, the use of my, or my Child(ren)’s, photograph, name or likeness, or any or all of them, by the Program/Research Foundation for its business promotion activities. I further understand that all grants of permission and consent, and all covenants, agreements and understandings contained herein are irrevocable.I acknowledge and represent that I am over the age of eighteen (18), that I have read the entire document, that I understand its terms and provisions, and that I have signed it knowingly and voluntarily on behalf of myself and/or my minor Child(ren).

Yes, I grant the permission to release of photos/videos. *

Primary Contact Name *
Relationship *
Phone No. 1 *
Phone No. 2
Address *
City *
State *
Zip Code *
Email Address *

Secondary Contact Name *
Relationship *
Phone No. 1 *
Phone No. 2
Address *
City *
State *
Zip Code *
Email Address *

Third Contact Name
Relationship
Phone No. 1
Phone No. 2
Address
City
State
Zip Code
Email Address
I do not want to receive receive any future surveys and/or follow-up information at the contact information provided for Youth Activity purposes only.

Session1:	$250 non-refundable deposit *
Session 2:	$250 non-refundable deposit *

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49er Camp Registration

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Additional Resources

Friend 1 First Name
Friend 1 Last Name
School Grade in Fall 2024

Friend 2 First Name
Friend 2 Last Name
School Grade in Fall 2024