MTA Technology Youth Tour Application

Full Name*

Date of Birth*

Grade Level (Fall of 2024)*

Address*

City*

Zip*

Phone Number*

Please use valid format.

Parent/Guardian Name*

Parent/Guardian Phone Number*

Please use valid format.

Parent/Guardian Email*

Chaperone Name*

Chaperone Phone Number*

Please use valid format.

Emergency Contact*

Emergency Contact Phone Number*

Please use valid format.

Known Food Allergies

I, , the parent or legal guardian of [Child] grant MTA my permission to use the photographs and video footage captured during educational field trips and visits for any legal use, including but not limited to: publicity, copyright purposes, illustration, advertising, and web content.

Furthermore, I understand that no royalty, fee or other compensation shall become payable to me by reason of such use.

I, the parent or legal guardian, consent to the above terms and conditions.

In checking this application you acknowledge and represent that you, your minor child, estate, heirs, administrators, executors and assigns, hereby release Matanuska Telecom Association, Inc (MTA), including their representatives, directors, officers, employees, and volunteers for and from and against any and all liability and responsibility whatsoever, for any and all damages, claims, or causes of action that you or your minor child may have for a loss, personal injury, disease or death arising out of any injury or accident sustained by you or your minor child which was not a result of MTA's negligence.

I, as the participant, consent to the above terms and conditions.

Date*

**Attendees are responsible for their own transportation.
**Chaperone is required for attendees.

MTA Technology Youth Tour Application

Wednesday, July 17, 2024