Steamers Application Step 1 of 2 50% Scholar's InformationScholar's Name First Last Sex*BoyGirlDate SchoolGradePlease enter a value less than or equal to 6.Parent's InformationParent's Name First Last PhoneEmail For the StudentWhy are you interested in this program?Name of teacher receiving recommendation formFor ParentsDoes your child have any allergies, medical conditions or other conditions that we need to know aboutYesNoDescribe medical condition. PLEASE READ THE FOLLOWING CAREFULLY AND SIGN ON Permission: I hereby grant permission for my child to participate in the STEAM Program at Nsoromma School, Inc. I hereby agree to hold harmless and release Nsoromma, its officers, directors, employees, students and representatives (“Releases”) from any claims of damage arising from my child’s participation in the program. I have signed this release with full recognition and appreciation of the risks of such activities, including risks associated with transportation to and from Nsoromma School, Inc. I agree that Nsoromma School, Inc. personnel are granted permission to authorize emergency medical treatment if necessary and that such action by persons shall be subject to the terms of this release. I understand that Releases assume no responsibility for any injury or damage that might arise out of or in connection with such emergency medical treatment I further agree that this consent and release shall be construed in accordance with the laws of the State of Georgia. If any term or provision of this consent and release shall be held illegal unenforceable or in conflict with any law governing this consent and release, the validity of the remaining portions shall not be affected.Insert Initials*Media Release: I grant my permission to The Nsoromma School, Inc., its representatives, employees or to those whom permission is granted by The Nsoromma School, to make motion or still pictures and television and video recordings including website uploads of these in which my child may appear. I understand that no payment whatsoever will be made to either my child or myself for his/her appearance in these photographs or video recordings. It is further understood that these photographs and/or video recordings are used solely for educational and/or promotional purposes. This consent shall be effective for five years from the date signed or until I withdraw my consent in writing. As evidenced by my signature below, I have carefully read and fully understand the terms and conditions of this permission form.Insert Initials*Name First Last Date Name First Last Date Tuition* Price: $300.00 This page is unsecured. Do not enter a real credit card number! Use this field only for testing purposes. Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20172018201920202021202220232024202520262027202820292030203120322033203420352036 Expiration Date Security Code Cardholder Name NameThis field is for validation purposes and should be left unchanged.