MIGIZI Enrollment Permission

MIGIZI Enrollment and Permission
MIGIZI uses this form for basic contact and demographic information. We also request that the parent/guardian completes our field trip and talent release form and a Release of Information form specific to your school district or education/employment status form if you are no longer in high school. These three items are required for enrollment.
Program *
Choose which program you wish to enroll in.
What are some things you want to happen for the summer? *

Arts and Crafts Sports Field Trips Community Building/Volunteering Cultural Teachings Other
What are some specific things you want to happen during summer? It could be things such as basketball, eating certain types of food, going to a specific place, exploring different subjects, etc. etc. *
Student Name *

First Name Last Name
Home Phone
If applicable.
Mobile Phone Number *
Please enter a valid phone number.
Student Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Birth Date *

Month Day Year
Reservation/Tribal Affiliation(s)
If applicable.
Are you tribally enrolled? *
School *
Write in your school name if applicable. If not, input N/A.
Grade *
If applicable. If not, input N/A
Are you behind on any credits in school?

Yes No
Student ID
Write in your student ID if applicable.
Health Concerns, Allergies, etc. *
If nothing, input N/A
Highest level of education attended *
Parent/Guardian Name *

First Name Last Name
Parent/Guardian Phone Number *
Please enter a valid phone number.
Parent/Guardian Email
example@example.com
Emergency Contact *

First Name Last Name
Emergency Contact Phone Number *
Please enter a valid phone number.
Emergency Contact Relationship *
Academic Transcript - Please submit your most updated academic transcript *

Cancel of
Where did you find MIGIZI or who told you about MIGIZI? *

Permission / Release Information
Field Trip Permission
Our programs will occasionally have students participate in field trip activities for which we would like to ask your permission. Additionally, we collect student projects other written material and digital likenesses (photographs and video) that will be used in digital portfolios and possibly marketing materials.

I grant permission to MIGIZI Communications, Inc. to transport my student:
Student Name *

First Name Last Name
grant permission for our child to attend field trip activities with MIGIZI Staff. (I) (We) the undersigned Parents(s)/Guardians(s) understand the adult leaders(s) will attempt to enforce reasonable safety precautions. However, I will not hold MIGIZI Communications, Inc. or any staff member connected with MIGIZI Communications, Inc. responsible in case of accident or injury to the above child. I understand that MIGIZI Communications, Inc. may not provide medical insurance coverage and that any or all medical expenses incurred by this child may be the sole responsibility of (I)(We) the undersigned Parent(s)/ Guardian(s).
(I)(We) the undersigned Parent(s)/Guardians(s) also authorize MIGIZI staff to act as agent(s) of the undersigned, to consent to any professional transportation (i.e. ambulance), X-ray examination, anesthetic, medical/surgical diagnosis or treatment and hospital care which is deemed advisable by and to be rendered from a licensed physician or surgeon. This authorization will remain effective for the duration listed above or till the child is returned to (I)(We) the undersigned Parent(s)/Guardians(s).
Parent/Guardian Signature

Clear
Student Signature

Clear
Transportation

I grant permission to MIGIZI Communications Inc. to transport my student,
Name *

First Name Last Name
to MIGIZI, after school and other sites as needed to complete their work assignments (i.e. travel to wetlands to collect water samples for science fair projects, visit solar energy farms for interviews).
Parent/Guardian Signature

Clear
Student Signature

Clear
Talent Release

I grant permission to MIGIZI Communications Inc. their successors and assignees to use my child's image and/or photographic likeness, comments, projects, or writings completed as part of MIGIZI programs in connection with any reproduction in print or digital form or for subsidiary (business) purposes.
Parent/Guardian Signature

Clear
Student Signature

Clear
Should be Empty:

MIGIZI Enrollment and Permission

Permission / Release Information

Field Trip Permission

Transportation

Talent Release