The Design/Code/Build Friends' Discount

Participant's Name*

First Last

Parent or Guardian's Name*

First Last

Parent or Guardian's Email Address

Parent or Guardian's Phone Number

Additional Contact for Emergencies*

First Last

Additional Contact Phone Number*

Additional Contact for Emergencies*

First Last

Additional Contact Phone Number*

Would you like to authorize additional people to pick up your child?

Yes
No

Pickup Alternate 1*

First Last

Pickup Alternate 1 Phone Number*

Pickup Alternate 2*

First Last

Pickup Alternate 2 Phone Number*

Your Troop Number, if applicable

Will your child need a laptop?*

Yes, my child won't be able to bring one.
No thanks, we have one my child can bring.

We have a few laptops to share, but it's best to bring your own if it is easily available for the most screen time.

Does your child have any allergies, food or otherwise?

Yes
No

Kindly explain if so:

Does your child have any special medical needs we should be aware of?

Yes
No

Kindly explain if so:

Name of Child's Physician:*

Physician's Phone Number:*

Health Insurance Plan*

Waiver: The undersigned releases from liability and indemnifies and holds harmless Design/Code/Build, Inc., its executive team, and its staffs and volunteers, and UCSD - UC Regents.

This release is for any and all liability for personal injuries and property losses or damage occasioned by or in connection with any activity or accommodations for this event, program, or camp. The undersigned further guarantees that their child understands that he or she must abide by all the rules from the Design/Code/Build staff.

Behavioral Responsibilities: The undersigned hereby assures Coordinators and Design/Code/Build staff that their child understands that she/he must conduct herself/himself in an appropriate manner which does not infringe upon the rights and safety of other participants of the program. Design/Code/Build coordinators and staff reserve the right to dismiss from the program and send home without program refund any student who does not abide by the program rules and who behaves in a manner deemed unsafe towards other camp participants.

Photo Release:*

Please check here if you consent to have your child’s photo appear on Design/ Code/Build’s website and materials.
Please check here if you do not wish to have your child’s photo appear on Design/ Code/Build’s website and materials.

Occasionally Design/Code/Build may use photographs taken during its classes and camps for promotional purposes. Design/Code/Build assures the undersigned that they will not release its students’ photographs in conjunction with their names or any other personally-identifying information.

I HAVE READ THIS RELEASE OF LIABILITY AND FULLY UNDERSTAND ITS TERMS, AND AM SIGNING IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

Parent or Guardian Signature*

Please type your name here to sign the form.