UNIVERSITY OF NORTH TEXAS

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

Please select from one of the following:
Camper Status *
Name *
Name
Home Address *
Home Address
Home Phone
Home Phone
Cell Phone *
Cell Phone
Gender *
Date of Birth *
Date of Birth
Please list the name(s) of anyone you wish to room with.
Director's Name *
Director's Name
Director Work Phone *
Director Work Phone
Director Cell Phone *
Director Cell Phone
Parent/Guardian Name *
Parent/Guardian Name
Parent/Guardian Work Phone *
Parent/Guardian Work Phone
Parent/Guardian Cell Phone *
Parent/Guardian Cell Phone
Emergency Contact *
Emergency Contact
Emergency Contact Phone *
Emergency Contact Phone
Consent and Responsibility Clause
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 2017 SASI Camp at The University of North Texas.
Parent Signature *
Parent Signature
Student Signature *
Student Signature