The Sweeney Experience

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The Sweeney Experience Participant Tickets*

<Please include all adults and children 3 years and older.

Participant 1 Information - Child with diabetes

Participant 1 Name:*

Child with diabetes

First Last

Participant 1 Type*

Participant 1 Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Participant 1 Email

Participant 1 Phone

Participant 1 Gender:*

Participant 1 Date of Birth*

Participant 1 Age*

Participant 1 T-Shirt Size:*

Is Participant 1 Diabetic?*

Has Participant 1 attended Camp Sweeney before?*

Participant 1 FOOD ALLERGIES and/or Preferences, if any:

Participant 2 Information - Guardian

Participant 2 Name:*

Parent or Guardian (at least one guardian must accompany child)

First Last

Participant 2 Type*

Is participant 2's address the same as participant 1?*

Yes

Participant 2 Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Participant 2 Email*

Participant 2 Phone*

Participant 2 Gender:*

Participant 2 T-Shirt Size:*

Is Participant 2 Diabetic?*

Has Participant 2 attended Camp Sweeney before?*

Participant 2 FOOD ALLERGIES and/or Preferences, if any:

Participant 3 Information

Participant 3 Name:*

First Last

Participant 3 Type*

Is participant 3's address the same as participant 1?*

Yes

Participant 3 Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Participant 3 Email

Participant 3 Phone

Participant 3 Age*

Participant 3 Gender*

Participant 3 T-Shirt Size:*

Is Participant 3 Diabetic?*

Has Participant 3 attended Camp Sweeney before?*

Participant 3 FOOD ALLERGIES and/or Preferences, if any:

Participant 4 Information

Participant 4 Name:*

First Last

Participant 4 Type*

Is participant 4's address the same as participant 1?*

Yes

Participant 4 Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Participant 4 Email

Participant 4 Phone

Participant 4 Age*

Participant 4 Gender*

Participant 4 T-Shirt Size:*

Is Participant 4 Diabetic?*

Has Participant 4 attended Camp Sweeney before?*

Participant 4 FOOD ALLERGIES and/or Preferences, if any:

Participant 5 Information

Participant 5 Name:*

First Last

Participant 5 Type*

Is participant 5's address the same as participant 1?*

Yes

Participant 5 Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Participant 5 Email

Participant 5 Phone

Participant 5 Age*

Participant 5 Gender*

Participant 5 T-Shirt Size:*

Is Participant 5 Diabetic?*

Has Participant 5 attended Camp Sweeney before?*

Participant 5 FOOD ALLERGIES and/or Preferences, if any:

Participant 6 Information

Participant 6 Name:*

First Last

Participant 6 Type*

Is participant 6's address the same as participant 1?*

Yes

Participant 6 Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Participant 6 Email

Participant 6 Phone

Participant 6 Age*

Participant 6 Gender*

Participant 6 T-Shirt Size:*

Is Participant 6 Diabetic?*

Has Participant 6 attended Camp Sweeney before?*

Participant 6 FOOD ALLERGIES and/or Preferences, if any:

Toddler Information

Will you be bringing a child under the age of 3?*

Toddler Details

Toddler's Name

Toddler's Gender

Toddler's Age

Payer Information

Payer / Cardholder Name*

First Last

Payer / Cardholder Street Address*

Credit card billing address

City*

State*

Zip Code*

Email*

A receipt will be e-mailed to this address.

Phone*

Your Payment Information

Coupon Code, if any

Total to be charged to your credit card today

Payment Option:

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

INDEMNITY AND RELEASE. PLEASE READ CAREFULLY.

I, the Parent/Guardian, on behalf of myself and my minor child(ren) understand that use of the Southwestern Diabetic Foundation and Camp Sweeney facilities and participation in facility programs and events creates a risk of injury and therefore expressly consent to and assume all risks associated with use of the Southwestern Diabetic Foundation and Camp Sweeney facilities and participation in their programs and events, even those which are not specifically foreseeable, and release, indemnify, defend, and hold harmless Southwestern Diabetic Foundation and Camp Sweeney and their directors, officers, employees, and agents (the “Released Parties”), from any loss, liability, claim, action, or suit (“Claim”) arising or alleged to arise from (A) bodily injury or personal injury suffered by any party on the Southwestern Diabetic Foundation and Camp Sweeney facilities, (B) bodily injury or personal injury caused by a participant in facility programs and events and/or (C) property damage or loss suffered in connection with, or as a result of, my or my minor child(ren)’s use of Southwestern Diabetic Foundation and Camp Sweeney facilities or participation in their programs and events, regardless of whether such claims and actions are founded in whole or in part upon alleged negligence of the Indemnified Parties. I, an adult person listed below, on behalf of myself and my minor child(ren) specifically and explicitly release, indemnify and hold harmless the Released Parties (defined above) from all liability, claims, demands, actions or rights of action, or damages of any kind including but not limited to those arising out of or relating to any one or more of the Released Parties’ own sole, contributory and/or comparative negligence. I knowingly and voluntarily release, indemnify and hold harmless the Released Parties from any such claims. I have read and understand this waiver. This Indemnity and Release is made and is performable in Cooke County, Texas. I agree that exclusive venue for all claims arising from or related to this agreement, including claims for personal injury, lies in Cooke County, Texas. Pictures and video/audio recordings may be taken of the participants and staff the Sweeney Experience day. I give the Southwestern Diabetic Foundation, Inc. permission to use the pictures and video/audio recordings of our family in any of its publicity campaigns and/or websites. We agree to abide by the behavioral rules and procedures set forth by Camp Sweeney for the safety of all participants and staff. Per my signature below, we have read and agree to all the above releases and authorizations.

Signature of Participant 2 - Guardian/Parent*

Signature of adult (Participant 3)*

By signing, participant acknowledges and agrees to all the above releases and authorizations.

Signature of adult (Participant 4)*

By signing, participant acknowledges and agrees to all the above releases and authorizations.

Signature of adult (Participant 5)*

By signing, participant acknowledges and agrees to all the above releases and authorizations.

Signature of adult (Participant 6)*

By signing, participant acknowledges and agrees to all the above releases and authorizations.

Date*