2025 Ohio Regional Braille Challenge - Southern Division

2025 Ohio Regional Braille Challenge - SOUTHERN DIVISION (Cincinnati) - Student Permission Form

Hosted by: Clovernook Center for the Blind & Visually Impaired

Location: iSPACE, 10020 Reading Rd, Blue Ash, OH 45241

When: Wednesday, February 26, 2025

Must be completed by parental/legal guardian and submitted by Friday, January 31, 2025. If you have questions or need helping filling out this form, please contact our Regional Coordinator, Stephanie Jones, by email at sjones@clovernook.org. Only contests submitted with a signed permission form attached will be eligible for Braille Challenge Finals.

Once a parent has submitted this form, your child's TVI will receive a request to fill out additional paperwork.
Student's First and Last Name*

First NameLast Name
Student's Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student's Home County*
Student's School*
Student's School County*
County where school is located
Student's Grade in School for the 2024-25 School Year*
Birthdate*

MonthDayYear
Date
Age*
Gender:*

FemaleMaleNon-binaryDecline to Answer
T-Shirt Size:*

Youth SmallYouth MediumYouth LargeYouth XL/Adult SmallAdult MediumAdult LargeAdult XLAdult 2XLAdult 3XL
TVI's Full Name (Your child's TVI will be asked to fill out additional paperwork to finalize your child's registration.)*

First NameLast Name
TVI's Email Address*
example@example.com
Parent/Guardian 1 First and Last Name*

First NameLast Name
Parent/Guardian 1 Email*
example@example.com
Parent/Guardian 1 Telephone Number*
Please enter a valid phone number.
Parent/Guardian 2 First and Last Name (optional)

First NameLast Name
Parent/Guardian 2 Email (optional)
example@example.com
Parent/Guardian 2 Telephone Number (optional)
Please enter a valid phone number.
Who will be attending the event with your student? Please list all persons attending with/on behalf of your student for headcount purposes.*
Is the adult attending with the student a:*

ParentTVIParaprofessionalOther
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Emergency Contact - Relationship to Child*
Assistive Technology Description: Please answer the below questions to the best of your ability. We use this information to track what devices Braille Challenge participants are using.
Have you ever used a refreshable braille display?*

YesNo
Do you have regular access to a refreshable braille display or braille notetaker?*

YesNo
If yes, what is the name of the device you use
Have you paired a refreshable braille display or notetaker to an iPad, iPhone, or Android device?*

YesNo
PERMISSION

As the parent or guardian of the contestant, I hereby give permission for the contestant to participate in the upcoming Braille Challenge preliminary contest and, if contestant qualifies, the Braille Challenge Finals and awards ceremony in Los Angeles, CA (collectively "Events"

LIABILITY RELEASE AND INDEMNIFICATION

In consideration of Braille Institute of America, Inc. ("BIA") permitting contestant to participate in the Events, I, on behalf of myself, the contestant, our heirs, successors and assigns, hereby waive and release, and agree to indemnify and hold harmless, BIA, its employees, officers, directors, volunteers and agents, including regional coordinators (collectively "Releasees") from, any and all claims, including claims of negligence, resulting in any physical or psychological injury, illness, damages, or economic or emotional loss, arising from or related to the contestant's participation in the Events.

I have read this permission and release form, and understand that by signing it, I am giving up substantial rights I and/or the contestant would otherwise have to sue or recover damages for losses occasioned by the Releasees’ fault. I sign this permission and release form voluntarily.
Electronic Signature of Parent, Guardian, or 18+ Student*

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PHOTOGRAPHIC AND RECORDING RELEASE

I hereby authorize BIA to photograph, videotape, or otherwise record by visual, audio, electronic or manual means, the name and visual likeness and/or voice or other sounds created by the above contestant (collectively "Reproductions" BIA may use, distribute, permit, copyright, and/or license the Reproductions in any exhibition, display, publication, solicitation, or promotional or educational material, in any format, or on any website including without limitation BIA's website and social networking websites such as Facebook, Instagram, or YouTube without compensation to the contestant, the contestant's heirs, successors or assigns.
Electronic Signature of Parent, Guardian, or 18+ Student

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