DNOVA Creative Center Subscription Form

DNOVA CREATIVE CENTER

MEMBERSHIP FORM

Produced by
The Diversity & Innovation Institute
The DNOVA Creative Center is a vibrant hub designed for high school students to collaborate, learn, and grow. Serving as an after-school space during the week, the DCC also hosts private events, workshops, and community gatherings. It fosters creativity, STEM learning, and community engagement.

To join, parents/guardians must complete this membership form. If you need a subscription for more than one participant, please submit a separate form for each child. You may save your progress and return to this form at any time by clicking the button at the bottom of the page.

Participant Information
Student's Legal Name*

First NameLast Name
Student's Date of Birth*

MonthDayYear
Date
Student's Email*
example@example.com
Student's Phone Number*
Please enter a valid phone number.
Student's Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student's Current Grade*
Student's High School*

Participant's Demographics

DNOVA values diversity and equity in STEM fields. To that end, we seek to ensure diversity in our programs. Collecting demographic data from our participants helps us evaluate our success in this objective. Responses will not affect entrance to the program.
Does the participant have a specialized Individual Education Plan?*

YesNo
Is the participant a Limited English Proficiency student?*

YesNo
Does the student participate in a free or reduced meal program?*

Yes, they receive free mealsYes, they receive reduced price mealsNo
Participant's Gender*
Participant's ethnic background is best described as:*
Participant identifies their race as:*
Participant is under custody of:*

Emergency Contact Information
Would you like to add additional emergency contacts other than the parent/guardian(s)?*

YesNo
Emergency Contact Name*

First NameLast Name
Emergency Contact's Relationship to Student*
Emergency Contact's Phone Number*
Please enter a valid phone number.
Emergency Contact's Email*
example@example.com

Medical Information
Does this student have any allergies or dietary considerations?*

YesNo
Allergies/Dietary Considerations*
Does this student have any present health conditions or injuries?*

YesNo
Present Health Conditions/Injuries*
Does this student have any past health conditions/injuries that we should be aware of?*

YesNo
Past Health Conditions/Injuries*
Please list any medications the participant is currently taking. If none, write "N/A"*
Has this student received the COVID-19 vaccine?

YesNoPrefer not to answer
Any other information that would be relevant in the event of emergency medical treatment:

Insurance Information

Parents or legal guardians are responsible for the cost of a minor's medical treatment. When available, insurance information will be processed by the health facility performing the treatment; otherwise you will be contacted for payment by cash, check, or credit card.
Would you like us to provide insurance information for this student in the event of an emergency?*

YesNo, I'd like to be contacted directly about medical payments
Insurance Company*
Policy Holder's Name*

First NameLast Name
Policy Number*
Member ID*
Policy Holder's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Policy Holder's Relationship to Student*

Consent for Medical Treatment of a Minor
I, as the parent or legal guardian of the aforementioned DNOVA Creative Center Participant, grant the following authorization for medical and/or surgical treatment of this minor by a health care professional should the need arise while they are at the DNOVA Creative Center.
Please check and complete one (1) of the following:*

I grant permission to the directors, assistants, or other persons responsible for her/his care to act on my behalf for said minor in granting permission for evaluation and treatment of medical or psychological problems. I understand that should a major medical or psychological problem arise; reasonable attempts will be made to notify me by telephone. In the event that I cannot be reached, I give my consent to such medical treatment as deemed necessary, including surgery, x-ray examinations, and anesthesia to be rendered to said minor by a licensed physician or nurse.I do not wish medical care of any kind, except in case of an emergency.I authorize limited medical care specified below:
If authorizing limited medical care (checked above), please provide details of limited authorized medical care:*
Signature for Medical Care Authorization*

Clear
Date*

MonthDayYear
Date
I understand that DNOVA Creative Center staff members are unable to administer medication. If a minor cannot self-medicate, a parent/guardian must come to the program to administer any required medications.

Consent and Release Form for Interviewing, Photographing and Videotaping

I hereby consent to be interviewed, photographed, filmed, videotaped, have my voice recorded, and/or have my personal likeness recorded through other visual means (collectively, referred to as “Personal Images”), and authorize the Diversity & Innovation Institute and companies with whom it collaborates (collectively, “DNOVA”) to use, release, publish, exhibit, post on the Internet, in CD-ROMs or any other medium any of my Personal Images, as described below and understand and acknowledge by signing this consent form the following:

By signing this form, I hereby give permission to DNOVA to use my Personal Images in whatever medium deemed appropriate by DNOVA for any of the following purposes: (i) public relations; (ii) marketing & social media; and (iii) training & education. DNOVA will not use the Personal Images for any other purposes.
- I understand that my Personal Images may be seen and used by DNOVA throughout the world and hereby give consent to such worldwide use for the purposes stated in this consent form.
- I understand that my consent is voluntary, that I am not required to sign this consent and that I may in fact refuse to sign it, thereby prohibiting DNOVA from obtaining or using any Personal Images of me.
- I have the right to revoke my consent at any time, which revocation must be in writing and submitted to DNOVA at the following address: the Diversity & Innovation Institute, 9100 Purdue Road, Suite 410, Indianapolis, IN 46268; or via email at contact@dnova.org.
- I release and discharge DNOVA, its officers, agents and employees, and each and all persons involved in creating my Personal Images from any liability connected with the taking, recording, filming or publication of said interviews, photographs, slides, computer images, videotapes or voice recordings.
- I waive all rights I may have to claims for payment or royalties in connection with any exhibition, televising, internet posting, or other publication of my Personal Images, irrespective of whether a fee for its use is charged by any third party.
- If I have any questions about my privacy rights under this form, I understand that I may contact DNOVA at 317-703-7836 or by writing at the following address: the Diversity & Innovation Institute, 9100 Purdue Road, Suite 410, Indianapolis, IN 46268, or by emailing to contact@dnova.org.
If the subject of the personal images is under 18 years old, the parent or legal guardian must sign below.

By signing this Consent and Release Form, I consent to allow the minor named below to participate in the activities described above and allow the information obtained from the below named minor to be used and shared as described above. I represent and warrant that (i) I am eighteen (18) years of age or older and am legally competent to execute this Consent and Release Form under the laws of my country, (ii) I have the legal authority to represent the below named minor (iii) I have read and understand this Consent and Release Form and (iv) I have had an opportunity to ask questions about the use of the below named minor’s Personal Images, understand their purported use, knowingly consent to such use and voluntarily sign this Consent and Release Form on behalf of the below named minor.

You may request a copy of this Consent and Release Form by emailing contact@dnova.org.
Please select one:*

Yes, I have read and consent to the Consent and Release Form for Interviewing, Photographing, and Videotaping (United States). I give permission for my child to be interviewed, photographed, or recorded by DNOVA for approved uses.No, I do not consent to the Consent and Release Form for Interviewing, Photographing, and Videotaping (United States). I do not give permission for my child to be interviewed, photographed, or recorded by DNOVA.
Name of Minor*
Name of Parent/Guardian*
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
If the subject of the personal images is 13 to 17 years old, they are required to acknowledge that their participation is voluntary by signing below.

You do not have to do this. No one will be mad at you if you refuse to do this or if you decide to quit.

As stated below, I willingly agree to participate in this project. I understand that my image and personal information may be displayed globally via the means described previously.

Fill this section if consenting to the "Consent and Release Form for Interviewing, Photographing and Videotaping (United Stat
Participant's Name*
Participant's Signature*

Clear
Date*

MonthDayYear
Date

Participant Acknowledgement & Signature
No student will be allowed to participate unless this form is completely filled-out and signed by the participant and a parent or guardian.

Participant must agree to the DNOVA Creative Center Behavior Policy and other terms (consent forms and waivers) for participation at the DNOVA Creative Center. Participant must review, agree to, and complete all necessary information needed.

The undersigned assumes full responsibility for the risk of bodily injury and death, whether due to the negligence or gross negligence of the Released Parties or otherwise. The undersigned voluntarily accepts those risks. We understand that this Release includes all claims based on actions, omissions, negligence or gross negligence of the Diversity & Innovation Institute, whether a COVID-19 infection occurs before, during or after participation at the DNOVA Creative Center. We understand that it is our sole and exclusive responsibility to purchase health insurance and agree to be liable for and pay all costs and expenses incurred with any medical and/or hospital services rendered to the undersigned, my child and/or children and/or family as a result of any activities associated with the Diversity & Innovation Institute.

The undersigned acknowledges that this Release, Waiver, Assumption of Risk and Indemnification Agreement is intended to be as broad and inclusive as permitted by law, and that if any portion of this Agreement is held to be invalid, it is agreed that the balance of the Agreement shall; notwithstanding, continue in full legal force and effect.

The undersigned acknowledges that he/she has carefully read the above Agreement and knows and understands its contents, knows and understands that by signing this Agreement, he/she voluntarily gives up substantial rights and assumes the risk of injury and/or death for the minor child and/or children and signs this Agreement as his/her own free act.

The Center reserves the right, upon notification of parents, to send home any student during any session for improper dress, conduct, language, or attitude which, in the judgment of the administrative or counseling staff, is deemed detrimental to the other participants or smooth operation of the program. Furthermore, if in the judgment of the administrative or coordinating staff, the student’s conduct violates any of the rules and regulations, the student will be sent home and referred to appropriate authorities.
I,Participant's name* have read, understand, and agree to follow the DNOVA Creative Center Behavior Policy and the rules. I know that by attending the DNOVA Creative Center, I’m agreeing to follow the expectations for behavior, safety, and participation. I understand that if I act in a way that goes against these rules, I may be asked to leave the center. I also understand that I am responsible for my actions, and that participating in activities comes with some risks. I agree to be respectful, safe, and responsible while I’m part of the program.
Participant's Signature*

Clear
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date

DNOVA Creative Center Membership Fee
Enjoy flexible membership options with special discounts through December 31, 2025:
- Daily Rate: $15/day (25% off regular $5/hr)
- Weekly Rate: $60/week (40% off)
- Monthly Rate: $196/month (50% off)
How to make payments:

To secure your student's spot at the DNOVA Creative Center, please complete the payment on our website at dnova.org/dcc. You will be provided instructions via email once this form is completed.
Please select one:*

I would like to secure my students' first week and pay $60I would like to secure my students' first month and pay $196I would like to secure my students' first day and pay $15
Should be Empty:

Participant Information

Participant's Demographics

Parent/Guardian Information

Program Information

Emergency Contact Information

Medical Information

Insurance Information

Consent for Medical Treatment of a Minor

Consent and Release Form for Interviewing, Photographing and Videotaping

Participant Acknowledgement & Signature

DNOVA Creative Center Membership Fee