STEM Learning labs registration form

Student Information

Students Name*

First NameLast Name

Birth Date

MonthDayYear

School & Grade*

SchoolGrade

Gender*

Ethnicity *

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Information

Name*

First NameLast Name

Cell Number*

E-mail*

example@example.com

How many children in the family or living in the home?*

Select the range total family income income *

Is another language spoken at home? If yes which language(s)?*

Emergency Information

Emergency Contact's Name*

First NameLast Name

Relationship

Phone Number*

Does the camper have any allergies, chronic illness, or medical conditions? If yes, please describe.

Informed Consent and Acknowledgement I hereby give my approval for my child’s participation in any and all activities prepared by Johnson College during the selected program. In exchange for the acceptance of said child’s candidacy by Johnson College ., I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Johnson College. and all its respective officers, agents, and representatives from any and all liability for injuries to the said child arising out of traveling to, participating in, or returning from selected camp sessions. In case of injury to said child, I hereby waive all claims against Johnson College . including all instructors, staff and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event.

Photo Release

I hereby give Johnson College the absolute and irrevocable right and permission, with respect to the quotations/photographs/video/film/audio recording that he/she has taken of me or in which I may be included with others:

(a) To copyright the same in his or her own name or any other name that he or she

may choose. (b) To use, reuse, publish and republish the same in whole or in part, individually or in

conjunction with other quotations/photographs/video/etc., in any medium and for any purpose whatsoever, including (but not by way of limitation) illustration, promotion,

advertising and trade (c) To use my name in connection therewith if he or she so chooses.

I hereby release and discharge Johnson College from any and all claims and demands arising out of connection with the use of the quotation/photographs/video/film/audio recording, including any and all claims for monetary compensation, damages, libel, slander, invasion of privacy or for any other claim based on the use of the said materials.

This authorization and release shall also ensure to the benefit of the legal representatives, licensees and assigns of Johnson College, as well as the person(s) for whom he/she took the quotations/photographs/video/film/audio recording.

Johnson College STEM Learning Labs