Jostens Workshop Registration Form - Richmond, VA

VIRGINIA SUMMER WORKSHOP
July 20-22 | University of Richmond
Register by June 1 to save!
1
Return
Return all forms
for your school
together at the same
time via mail to
Jeff & Kelly Carns
15215 Prairie Court
Culpeper, VA 22701
carnsj@jostens.com
Circle one: Elementary, Middle or High School, College or University
School Name: ___________________________________________
School Address: ___________________________________________
City: _____________________ State:____ Zip:__________
Jostens Representative: ___________________________________________
Jostens Job Number: ________________
Number of registrants including adviser: __________
Do any registrants have dietary restrictions or need for medication refrigeration?
Explain __________________________________________________________
2
Prices are listed per
registrant
$325 Tuition*
$275 Commuter
tuition*
$50 Late fee
per person
after June 1
$30 Lost access card
$50 Lost room key
* if paid by
June 1, 2010
first name last name email address t-shirt size (circle one)
circle one
male/female
student/adviser
mobile phone
circle one
commuter | dorm resident
Registrant 1
S M L XL 2XL
check here if registering for the
photography track
business manager track
first name last name email address t-shirt size (circle one)
circle one
male/female
student/adviser
mobile phone
circle one
commuter | dorm resident
Registrant 2
S M L XL 2XL
check here if registering for the
photography track
business manager track
first name last name email address t-shirt size (circle one)
circle one
male/female
student/adviser
mobile phone
circle one
commuter | dorm resident
Registrant 3
S M L XL 2XL
check here if registering for the
photography track
business manager track
first name last name email address t-shirt size (circle one)
circle one
male/female
student/adviser
mobile phone
circle one
commuter | dorm resident
Registrant 4
S M L XL 2XL
check here if registering for the
photography track
business manager track
first name last name email address t-shirt size (circle one)
Registrant 5
S M L XL 2XL
circle one
male/female
student/adviser
mobile phone
circle one
commuter | dorm resident
check here if registering for the
photography track
business manager track
For more information: bestyearbookcamp.com

Photo Track
Students enrolled in the
photo track will need to
bring their cameras and
will spend the course of
the workshop with the
photography group.
Payment
An invoice will be
emailed to the school
following registration.
The registration process
is not complete until
payment has been
received. Make checks
payable to Virginia
Yearbook Workshop.
3
Medical Release Form
Each student must
complete a medical
release form to be
returned prior to
attending the workshop.
Students will not be
permitted to attend the
workshop without the
proper release form.
In consideration of the educational opportunity provided, the above
student or adult, I/we the parent(s), legal guardian(s), or spouse of the
above named person, or myself, do hereby hold harmless, release and
forever discharge Jostens, Inc., Jostens Representatives and Concord
Embassy Suites at which the workshop described herein will be held,
and their officers, agents and employees from any and all claims,
demands, liability, actions, causes of action attorney fees and expenses
on account of damages to personal property or personal injury which
may result from causes beyond the control of, and/or without the
fault or negligence of Jostens, Inc. the named sales representative and
employees, during the workshop.
I/we also give permission that medical attention be administered to
the above named or myself in case of emergency. I/we understand that
any medical assistance of a more serious nature will be brought to our/
my attention as conditions permit. I understand that the emergency
contact will be notified as soon as such communication can be made.
first name last name email address t-shirt size (circle one)
circle one
male/female
student/adviser
mobile phone
circle one
commuter | dorm resident
Registrant 6
S M L XL 2XL
check here if registering for the
photography track
business manager track
first name last name email address t-shirt size (circle one)
circle one
male/female
student/adviser
mobile phone
circle one
commuter | dorm resident
Registrant 7
S M L XL 2XL
check here if registering for the
photography track
business manager track
first name last name email address t-shirt size (circle one)
circle one
male/female
student/adviser
mobile phone
circle one
commuter | dorm resident
Registrant 8
S M L XL 2XL
check here if registering for the
photography track
business manager track
first name last name email address t-shirt size (circle one)
circle one
male/female
student/adviser
mobile phone
circle one
commuter | dorm resident
Registrant 9
S M L XL 2XL
check here if registering for the
photography track
business manager track
first name last name email address t-shirt size (circle one)
circle one
male/female
student/adviser
mobile phone
circle one
commuter | dorm resident
Registrant 10
S M L XL 2XL
check here if registering for the
photography track
business manager track
*To register more students please duplicate the registration form
Rooming solutions:
Please list those sharing a room.
Occupancy of mixed genders will not be allowed.
Advisers interested in a single occupancy dorm room should contact the workshop
immediately. Single rooms are available on a first come, first serve basis.
List the registrants who will be rooming together.
Room 1 Room 2 Room 3 Room 4
Room 5 Room 6 Room 7 Room 8
Return Form to:
Jostens
15215 Prairie Court
Culpeper, VA. 22701
In case emergency treatment is required, my/our health insurance plan
number and carrier are:
Medical Information
Participant’s name _________________________________________
Insurance carrier _________________________________________
Policy number _________________________________________
Parent/Guardian _________________________________________
Adult’s signature _________________________________________
Date _________________________________________
Emergency contact _________________________________________
Name _________________________________________
Phone _________________________________________
Alternate contact _________________________________________
Phone _________________________________________
Room 9 Room 10 Room 11 Room 12
4
Release Form:
All students attending the workshop must complete and return a medical release
form.

Virginia Yearbook Workshop
Release Form
Each student must
complete the release
form to be returned
prior to attending the
workshop.
Students will not be
permitted to attend the
workshop without the
proper release form.
In consideration of the educational opportunity provided, the below student or adult, I/
we the parent(s), legal guardian(s), or spouse of the below named person, or myself,
do hereby hold harmless, release and forever discharge Jostens, Inc., Jostens
Representatives and the University of Richmond at which the workshop described
herein will be held, and their officers, agents and employees from any and all claims,
demands, liability, actions, causes of action attorney fees and expenses on account of
damages to personal property or personal injury which may result from causes beyond
the control of, and/or without the fault or negligence of Jostens, Inc. the named sales
representative and employees, during the workshop. I/we also give permission that
medical attention be administered to the below named or myself in case of emergency.
I/we understand that any medical assistance of a more serious nature will be brought to
our/my attention as conditions permit. I understand that the emergency contact will be
notified as soon as such communication can be made. In case emergency treatment
is required, my/our health insurance plan number and carrier are listed below.
Participant’s name
School / Teacher
Insurance carrier
Policy number
Parent/Guardian
Adult’s signature
Date
______________________________________
______________________________________
______________________________________
______________________________________
______________________________________
______________________________________
______________________________________
Return Form
to:
Student will return this
form to his/her teacher.
The adviser will mail
forms to the address
below.
Jostens
15215 Prairie Ct,
Culpeper, VA
22701
Emergency contact
Name
Phone
Alternate contact
Phone
______________________________________
______________________________________
______________________________________
______________________________________
______________________________________
I hereby consent that all film or photos taken of me/my child at the Virginia Yearbook
Workshop on July 20-22, 2010, may be used by Jostens for educational or promotional
purposes without further consideration. I hereby give Jostens with respect to any
photographs and/or film taken of me/my child during the dates stated on this form, my
absolute and irrevocable right and permission to use, re-use and publish the same in
whole or in part, individually or in conjunction with other pictures in any medium for any
purpose whatsoever without any additional compensation to me. I agree that neither
Jostens nor anyone authorized by Jostens to use said photographs and/or film shall
have any liability for any distortion, alteration, optical illusion or use in composite form
that may occur or result from the use of said promotional materials. I further agree
that said promotional materials shall constitute Jostens sole property, with full right of
disposition thereof in any manner whatsoever as Jostens sees fit.
Signature of Participant / Parent: ________________________________________
Parent/Guardian approval must be given if student is under 18 years of age.