It's A Math Revolution Registration Form

It's A Math Revolution Registration Form

@ UCLA
Please Note: If you want to enroll additional siblings in the Math Revolution, a separate registration is required for each child.
The Math sessions are for 3rd through 8th grade only. It is recommended that Elementary and Middle school students attend both sessions for the best Math results.*

Session 1 , Saturday January 25, 2025 from 1-4 PM @ UCLASession 2, Saturday February 22, 2025 from 1-4 PM @ UCLATeacher's Assistant (this is for High School Students only 10th-12th grade)
Section I: Student Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Student's Email*
example@example.com
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Country*
Gender
Name of school you are currently attending.*
Current Grade*
What math class are you currently enrolled in?*
What would you like to learn more about?
If you selected other, please specify.
Do you have any diet restrictions or food allergies?*
If yes, please describe your diet restrictions or food allergies.
*A separate form must be filled out for each student enrolling in the session(s).
Section II: Parent/Guardian Information

Parent/Guardian 1
Name*

First NameLast Name
Parent/Guardian 1 Email*
example@example.com
My address is the same as student's address*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Country
Cell Phone*
Please enter a valid phone number.
Other Phone
Please enter a valid phone number.
Parent/Guardian 2
Name*

First NameLast Name
Parent/Guardian 2 Email*
example@example.com
My address is the same as student's address*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Country
Cell Number*
Please enter a valid phone number.
Other Number
Please enter a valid phone number.
Section III: Emergency Contact Information

*must be someone different than parent/guardian named above
Name*

First NameLast Name
Relationship*
Emergency Contact Email*
example@example.com
Cell Phone*
Please enter a valid phone number.
Other Phone
Please enter a valid phone number.
Health Insurance Information
Member ID
Group Number
I do not have health insurance.
Section IV: Parental Consent for Photography and Participation in Evaluation Studies

Please indicate if you give permission for your child to participate in the following activities:
Photography*

Yes, I give permission for my child to be photographed for the Black Math Collective (BMC) and UCLA CEED, including still pictures, slides and video.No, I do not give permission for my child to be photographed through BMC and the UCLA, including still pictures, slides and video.
*I understand that photographs, slides and videos will be used for educational purposes, our official website, fundraising and/or to promote the Black Math Collective's (BMC's) mission and the mission of UCLA CEED.
Media/Photo Release*

I give permission for my child to be photographed or videotaped as part of his/her involvement in the Black Math Collective's and UCLA CEED's Saturday programs. I also give permission for his/her photo and/or image to be used in publications and/or promotional material associated with the BMC''s and UCLA CEED's Program.I do not give permission for my child to be photographed or video taped as part of his/her involvement in the Program. I also do not give permission for his/her photo and/or image to be used in publications and/or promotional material associated with the BMC's and UCLA CEED's Program.
Media Release of Information*

Yes, I hereby give permission for my child to participate in evaluation studies of BMC's. This includes observations of my child doing regular activities in the program, anecdotal notes regarding his or her progress towards meeting objectives and use of developmental assessments and other evaluation results. I understand that this information would be treated confidentially and that my child’s full name will not be used on any reports of the results except for confidential reports required by the state or school district.No I do not give my permission for my child to participate in evaluation studies for the BMC.
*I understand that photographs, slides and videos will be used for educational purposes, our official website, fundraising and/or to promote BMC's mission and the mission of UCLA CEED.
Please read the RELEASE AND WAIVER OF LIABILITY FOR ALL AFTER SCHOOL CLASSES AND PROGRAMS.
I have read the RELEASE AND WAIVER OF LIABILITY FOR ALL AFTER SCHOOL CLASSES AND PROGRAMS.*

YesNo
PARTICIPANT: In signing this Acknowledgement of Risk and Waiver of Liability I hereby acknowledge and represent that I am of legal age and have read this document in its entirety, understand it, and sign it voluntarily.*

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Participant's Name*

First NameLast Name
Date*

MonthDayYear
Date
PARENT/GUARDIAN 1: Participants who are under 18 years of age, or not legally competent, must sign above, and also must obtain the signature of a parent or legal guardian below: I certify that I am the parent or legal guardian of the above-named participant. On behalf of myself and my spouse, partner, co-guardian or any other person who may represent the participant, I have read the above agreement, I understand its contents, assent to its terms and conditions, and sign it of my own free act. I acknowledge that my dependent and I have agreed to the terms and conditions of my dependent’s participation, and I hereby give my consent to participation by my dependent, and to receive medical treatment determined to be necessary. I further agree to hold harmless, indemnify and defend BMC and all BMC Staff Members from and against all claims, demands or suits that my dependent has or may have. I further agree to hold harmless, indemnify and defend UCLA CEED and all UCLA CEED Staff Members from and against all claims, demands or suits that my dependent has or may have.*

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Parent/Guardian 1's Name*

First NameLast Name
Date*

MonthDayYear
Date
PARENT/GUARDIAN 2: Participants who are under 18 years of age, or not legally competent, must sign above, and also must obtain the signature of a parent or legal guardian below: I certify that I am the parent or legal guardian of the above-named participant. On behalf of myself and my spouse, partner, co-guardian or any other person who may represent the participant, I have read the above agreement, I understand its contents, assent to its terms and conditions, and sign it of my own free act. I acknowledge that my dependent and I have agreed to the terms and conditions of my dependent’s participation, and I hereby give my consent to participation by my dependent, and to receive medical treatment determined to be necessary. I further agree to hold harmless, indemnify and defend BMC and all BMC Staff Members from and against all claims, demands or suits that my dependent has or may have. I further agree to hold harmless, indemnify and defend UCLA CEED and all UCLA CEED Staff Members from and against all claims, demands or suits that my dependent has or may have.*

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Parent/Guardian 2's Name

First NameLast Name
Date

MonthDayYear
Date
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It's A Math Revolution Registration Form

Please Note: If you want to enroll additional siblings in the Math Revolution, a separate registration is required for each child.

Section I: Student Information

Section II: Parent/Guardian Information

Section III: Emergency Contact Information

Section IV: Parental Consent for Photography and Participation in Evaluation Studies