Design the Future Summer Experience 2020 Registration

How many children are you purchasing tickets for today?*
- One
- Two
Parent or Guardian Name*
First Last
Is you or your spouse a military veteran?*
- Yes
- No
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Please choose a unique username*
for access to the wearedreamtank.com website
Youth Information:
For each child, please fill out the requested information below. There are separate fields for each child (labeled child #1 and child #2) including a video application and content and liability releases.
Name of Child (#1)*
First Last
Age of child (#1)*
*Ages 8-30*
Has your child (#1) had experience with any of the following?
- Entrepreneurship
- Programming
- Graphic Design
- Photo / Video Editing
- Social Media
Is there anything else we should know about your child (#1)?
Name of Child (#2)
First Last
Age of child (#2)
*Ages 8-30*
Has your child (#2) had experience with any of the following?
- Entrepreneurship
- Programming
- Graphic Design
- Photo / Video Editing
- Social Media
Is there anything else we should know about your child (#2)?
Releases
Use of Film and Photo Agreement (Child #1)*
I have read and agree to the below for Child #1
Dream Tank uses film and photography for projects, promotional and educational content. I set below my signature to evidence my full understanding of the agreement with all the terms listed below.

A. I grant DREAM TANKTM the right to use my son and/or daughter’s name, likeness, voice and biographical information for production, broadcast, and internet purposes of educational and promotional materials.

B. I authorize the use of my son/daughter’s image for anything related to DREAM TANKTM.

C. I release all of those involved with DREAM TANKTM from any liability for injury of any type that may arise from my son/daughter’s involvement. In consideration I will be released from any liability for injury of any type that may arise from my involvement with DREAM TANKTM which I otherwise could be held liable for arising from our involvement with DREAM TANKTM

D. I understand that the presentation, story, style and all other creative processes will be at the liberty of DREAM TANKTM, and that participation in DREAM TANKTM and promotional videos and photos is limited to the discretions of DREAM TANKTM
Use of Film and Photo Agreement (Child #2)*
I have read and agree to the below for Child #2
Dream Tank uses film and photography for projects, promotional and educational content. I set below my signature to evidence my full understanding of the agreement with all the terms listed below.

A. I grant DREAM TANKTM the right to use my son and/or daughter’s name, likeness, voice and biographical information for production, broadcast, and internet purposes of educational and promotional materials.

B. I authorize the use of my son/daughter’s image for anything related to DREAM TANKTM.

C. I release all of those involved with DREAM TANKTM from any liability for injury of any type that may arise from my son/daughter’s involvement. In consideration I will be released from any liability for injury of any type that may arise from my involvement with DREAM TANKTM which I otherwise could be held liable for arising from our involvement with DREAM TANKTM

D. I understand that the presentation, story, style and all other creative processes will be at the liberty of DREAM TANKTM, and that participation in DREAM TANKTM and promotional videos and photos is limited to the discretions of DREAM TANKTM
Dream Tank TM Camp Participants Release of Liability Form and Assumption of Risk Agreement (Child #1)*
I have read and agree to the following:
Our mission at Dream Tank is to offer the next generation of entrepreneurs a fun and creative space to bring dreams to life. Part of our accelerator involves outdoor activity and electronic equipment. This agreement is applicable for all programs with Dream Tank TM.

In consideration of being allowed to participate in any way in the program, related events and activities, I the undersigned, acknowledge, appreciate, and agree that:
The risk of injury from the activities involved in this program is possible.

I knowingly and freely assume, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASES or others, and assume full responsibility for my child’s participation.

I willingly agree to comply with the terms and conditions for participation. If any unusual significant hazard without my presence or participation, I will remove my child from participation and bring such to the attention of the nearest official immediately.

By participating in or attending any activity in connection with this program, whether on or off the premises, I consent to the use of any photographs, pictures, film or videotape taken of me or provided by me for publicity, promotion, television, websites or any other use, and expressly waive any right of privacy, compensation, copyright or other ownership right connected to same.

I, for myself and behalf of my child, and my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEMNIFY AND HOLD HARMLESS Dream Tank, Heidi Cuppari, its officers, officials, agents, and/or employees, other participants, sponsors, advertisers, and, if applicable, owners and lessors of premises used to conduct the event (RELEASEES), from any and all claims, demands, losses, and liability arising out of or related to any INJURY, DISABILITY OR DEATH MY CHILD may suffer, or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law.

I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
Dream Tank TM Camp Participants Release of Liability Form and Assumption of Risk Agreement (Child #2)*
I have read and agree to the following:
Our mission at Dream Tank is to offer the next generation of entrepreneurs a fun and creative space to bring dreams to life. Part of our accelerator involves outdoor activity and electronic equipment. This agreement is applicable for all programs with Dream Tank TM.

In consideration of being allowed to participate in any way in the program, related events and activities, I the undersigned, acknowledge, appreciate, and agree that:
The risk of injury from the activities involved in this program is possible.

I knowingly and freely assume, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASES or others, and assume full responsibility for my child’s participation.

I willingly agree to comply with the terms and conditions for participation. If any unusual significant hazard without my presence or participation, I will remove my child from participation and bring such to the attention of the nearest official immediately.

By participating in or attending any activity in connection with this program, whether on or off the premises, I consent to the use of any photographs, pictures, film or videotape taken of me or provided by me for publicity, promotion, television, websites or any other use, and expressly waive any right of privacy, compensation, copyright or other ownership right connected to same.

I, for myself and behalf of my child, and my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEMNIFY AND HOLD HARMLESS Dream Tank, Heidi Cuppari, its officers, officials, agents, and/or employees, other participants, sponsors, advertisers, and, if applicable, owners and lessors of premises used to conduct the event (RELEASEES), from any and all claims, demands, losses, and liability arising out of or related to any INJURY, DISABILITY OR DEATH MY CHILD may suffer, or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law.

I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
Participant Medical Information (Child #1)*
Please carefully read and complete the following form. All information will be held confidential and is in the interest of safety during your son or daughter’s program. Indicating “yes” in regards to any of the following questions does not automatically disqualify anyone from participating, but simply helps the guide be well prepared.
If you check any of the following boxes, please explain to a program counselor in private.
Does your child currently have or have the history of:
- Bleeding or blood disorder
- Eating Disorders
- Hepatitis or other liver disease
- Neurological problems (Seizures, Epilepsy)
- Dizziness or fainting episodes
- Treatment or medication for menstrual cramps
- Disorders of the urinary or reproductive tract
- Current or prior cardiovascular disease or other cardiovascular problems
- A family history of cardiac disease
- Gastrointestinal disturbances
- Diabetes
- Hypertension
- Frostbite or Frostnip
- Heat Stroke or other heat related illness
- High Blood pressure
- Obesity
- Respiratory problems
- Unexplained chest pain, shortness of breath or palpitations
- High Cholesterol
- Knee, hip, ankle, shoulder, arm, hand or back injuries
- None of the Above
Participant Medical Information (Child #2)*
Please carefully read and complete the following form. All information will be held confidential and is in the interest of safety during your son or daughter’s program. Indicating “yes” in regards to any of the following questions does not automatically disqualify anyone from participating, but simply helps the guide be well prepared.
If you check any of the following boxes, please explain to a program counselor in private.
Does your child currently have or have the history of:
- Bleeding or blood disorder
- Eating Disorders
- Hepatitis or other liver disease
- Neurological problems (Seizures, Epilepsy)
- Dizziness or fainting episodes
- Treatment or medication for menstrual cramps
- Disorders of the urinary or reproductive tract
- Current or prior cardiovascular disease or other cardiovascular problems
- A family history of cardiac disease
- Gastrointestinal disturbances
- Diabetes
- Hypertension
- Frostbite or Frostnip
- Heat Stroke or other heat related illness
- High Blood pressure
- Obesity
- Respiratory problems
- Unexplained chest pain, shortness of breath or palpitations
- High Cholesterol
- Knee, hip, ankle, shoulder, arm, hand or back injuries
- None of the Above
Is your child currently taking any medications? Medication dosage and frequency (Child #1)*
Is your child currently taking any medications? Medication dosage and frequency (Child #2)*
Does your child have any known allergies to Food, Insects, Medication or other? (Child #1)*
Does your child have any known allergies to Food, Insects, Medication or other? (Child #2)*
Signature of Parent or Guardian
by signing you agree that you have read and that you and your child(ren) understand and will abide by the documents listed above.
Purchase
Ticket(s)*
- One Child ($1,500)
- Two Children (20% discount for child #2)
- Military Discount One Child (15% discount)
- Military Discount Two Children (15% discount)
Total
$0.00
Credit Card

American Express
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Card Number Expiration Date Security Code Cardholder Name
Comments
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Youth Information:

Releases

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