2023 London Brain Bee - Consent & Media Form

London Brain Bee

University of Western Ontario
Your son/daughter has expressed interest in participating in the London Brain Bee hosted by the University of Western Ontario on Saturday, April 1st.

This day gives students the opportunity to compete with other secondary students in London and surrounding area to qualify for a seat at the National Brain Bee. Beyond the trivia competition, students will participate in neuroscience demonstrations, mock patient diagnosis sessions, and a neuroanatomy scavenger hunt featuring real human brain specimens!

For more information, please visit our website.
Student Name:*

First NameLast Name
INFORMED CONSENT AND WAIVER OF LIABILITY

I, the undersigned, agree that the University of Western Ontario shall not be liable for any injury to the applicant or loss or damage of personal property, arising from or in any way resulting from his/her participation in the above program, UNLESS such injury, loss or damage is caused by willful neglect or negligent actions of the above parties for which it is in law responsible.
I declare having read Informed Consent and Waiver of Liability that I am aware of my son/daughter's involvement and consent to his/her participation in the above program.

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Parent/Guardian Signature
-OR-
I am over 18 years of age and declare having read this Informed Consent and Waiver of Liability.

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Student Signature
EMERGENCY CONTACT

Please provide the name and phone number of the person we should contact in case of emergency on event day.
Emergency Contact Name:*
Emergency Contact Phone Number:*
Please enter a valid phone number.
MEDIA RELEASE

This event may attract media attention. Participants may be photographed, interviewed, and/or videotaped by the media. They may also be photographed and quoted by the Brain Bee Team and its sponsors for promotional purposes including on the Brain Bee website and on social media.
I agree to be photographed and/or videotaped by the media, the Brain Bee Team and/or its sponsors. I give permission for this material to be printed, published, posted on the official Brain Bee website, and/or broadcast in the public forum.

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Student Signature
PLEASE NOTE THAT INCOMPLETE FORMS CANNOT BE PROCESSED.

This Brain Bee is an officially sanctioned event of The International Brain Bee.

All rights reserved.
Should be Empty:

London Brain Bee

INFORMED CONSENT AND WAIVER OF LIABILITY

EMERGENCY CONTACT

MEDIA RELEASE