2026 Student Permission Form - Ohio Regional Braille Challenge

2026 Ohio Regional Braille Challenge - Student Permission Form

Hosted by: Clovernook Center for the Blind & Visually Impaired

Must be completed by parent/legal guardian (or by student if over 18) and submitted by Friday, January 30, 2026. (Registrations received by December 15, 2025 will be entered into our Early Bird Drawing for some amazing prizes!) If you have questions or need help filling out this form, please contact our Regional Coordinator, Stephanie Jones, by email at sjones@clovernook.org or by phone/text at 901-428-2942. Only registrations submitted with a signed permission form attached will be eligible for Braille Challenge Finals.

Once a parent (or student over 18) has submitted this form, the student's TVI will receive a request to fill out additional paperwork.

This year we are thrilled to offer the Ohio Regional Braille Challenge in three locations across the state. We hope this will allow your student to participate at the location most convenient for you and your family. PLEASE NOTE that students may ONLY register and/or attend/compete at ONE location.

(If you should need to change your registration for any reason prior to the event, please contact our Regional Coordinator, Stephanie Jones, by email at sjones@clovernook.org or by phone/text at 901-428-2942. *If you reach out regarding a change, please know that the change is not final until you have received a confirmation email with the approved changes.)

Location choices are: (you may only select one option)

Northern Ohio - Tuesday, February 17, 2026 - Stark County ESC, 6057 Strip Ave NW, North Canton, OH 44720

Central Ohio - Thursday, February 19, 2026 - Beechwold Christian Church, 280 Morse Rd, Columbus, OH 43214

Southern Ohio - Tuesday, February 24, 2026 - College Hill Presbyterian Church, 5742 Hamilton Ave, Cincinnati, OH 45224

Select the Ohio Regional Braille Challenge Competition your student will attend:*

Northern Ohio - Tuesday, February 17, 2026 - Stark County ESC, 6057 Strip Ave NW, North Canton, OH 44720Central Ohio - Thursday, February 19, 2026 - Beechwold Christian Church, 280 Morse Rd, Columbus, OH 43214Southern Ohio - Tuesday, February 24, 2026 - College Hill Presbyterian Church, 5742 Hamilton Ave, Cincinnati, OH 45224

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 2025-26 School Year*

Birthdate*

Date

Age*

Gender:*

FemaleMaleNon-binaryDecline to Answer

T-Shirt Size:**

*All registered participants will receive a FREE short-sleeved t-shirt with the logo above. If you would like to order additional 2026 Ohio Regional Braille Challenge merch (short- or long-sleeved t-shirts, crewneck sweatshirts, hoodies, drawstring backpacks) or other Clovernook Spiritwear, please check out our order form at: bit.ly/ClovernookSpiritwear

Lunch (pizza or a boxed-type lunch) will be provided for participants. Please let us know below if your student will be eating the lunch provided or will bring their own lunch. (Some light Breakfast items will be available during morning registration as well.)

Participant will eat the lunch provided by Clovernook.Participant will NOT be eating the lunch provided and will bring their own lunch.

Please share with us if your student has any allergies or other medical concerns we should be aware of during the event (e.g., food allergies or sensitivities, etc.).

TVI's Full Name (The student's TVI will be asked to fill out additional paperwork to finalize registration.)*

First NameLast Name

TVI's Email Address*

example@example.com

Parent/Guardian 1 First and Last Name (or student if over 18)*

First NameLast Name

Parent/Guardian 1 Email (or student if over 18)*

example@example.com

Parent/Guardian 1 Telephone Number (or student if over 18)*

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 the student for headcount purposes. Please note that we cannot accommodate siblings who are not registered for the Braille Challenge. All programming is for participants and accompanying adults (parents/guardians and education professionals) only.*

Is the adult(s) 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 Student*

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 (or student if over 18), 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 Student if over 18*

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 Student if over 18

CLOVERNOOK CENTER FOR THE BLIND & VISUALLY IMPAIRED

PERMISSION STATEMENT AND RELEASE FROM LIABILITY

NOTICE - THIS IS A LEGAL DOCUMENT THAT CONTAINS A GENERAL RELEASE.

It should be read carefully and understood fully before signing.

1. Consent/Permission. I voluntarily agree to participate in activities, programs, classes, services and/or events provided, sponsored or organized by Clovernook Center for the Blind and Visually Impaired (“Clovernook”), including but not limited to Summer Camp events in and around the city of Cincinnati, travel to and from the locations at which the Summer Camp events may occur, any Braille Challenge event and/or any activities through the Pediatric Low Vision Program, and/or other Clovernook Center activities (collectively the “Activities”). Alternatively, I am the parent or legal guardian of the child participant named below and hereby give permission for that child to participate in the Activities. Being a participant in the Activities or the parent or legal guardian of a child participating in the Activities (“Participant”), I hereby agree as follows:

2. Assumption of the Risk. Participant is participating voluntarily in the Activities. I certify that Participant is physically able to participate in the Activities and that I know of no physical or psychological impairments that would in any manner limit Participant’s participation in the Activities. I understand that the Activities may involve foreseeable and unforeseeable inherent risks, hazards, and dangers. I hereby expressly and specifically assume the risk of damage, injury, harm or death that Participant may face in connection with the Activities.

3. Waiver and Release. I, on behalf of myself, my child, and my and/or their heirs, successors, assigns, executors, and administrators, do hereby release, forever discharge, indemnify, and hold harmless Clovernook and its directors, officers, employees, volunteers, representatives, agents, successors and assigns (collectively the “Released Parties”) from any and all liability, claims, demands and causes of action of whatever kind or nature, either in law or in equity, arising out of or relating to Participant’s participation the Activities, including but not limited to any claim for any bodily or psychological injury, personal injury, illness, death, economic or emotional loss, or property damage that may arise out of, occur during or result from the Activities, regardless of whether caused in whole or in part by an act or omission of a Released Party.

4. Medical Treatment. I release, forever discharge, indemnify, and hold harmless the Released Parties from any claim, demand or cause of action whatsoever arising out of or relating to any first aid or medical treatment rendered in connection with the Activities. I further authorize Clovernook to seek emergency medical treatment for Participant in the event of an accident, injury, illness. In the event of an emergency, please contact:

EMERGENCY CONTACT Name*

First NameLast Name

EMERGENCY CONTACT Relationship*

EMERGENCY CONTACT Phone Number*

Please enter a valid phone number.

5. Media Release. I grant Clovernook permission to photograph, videotape, or otherwise record by visual, audio, electronic or manual means, the visual likeness and/or voice or other sounds created by Participant (collectively “Reproductions”). I further grant and convey to the Released Parties all right, title and interest in the Reproductions, including but not limited to the right to use Participant’s name and any Reproductions in any and all Clovernook publications or advertisements in print, television, online (including without limitation, its websites or pages on Facebook or other social media sites) and any other media and/or to share the Reproductions with Clovernook partners for their marketing or other purposes, without compensation to me or Participant. This consent is irrevocable and is without payment. The Reproductions will become the property of Clovernook, and I will have no ownership interest in the Reproductions and waives any rights, privileges or claims based on any right of publicity, privacy, ownership or any other rights arising, relating to or resulting from the Reproductions. I waive the right to inspect or approve any Reproductions, and I waives any right to royalties or other compensation arising or related to their use by Clovernook.

SELECT ONE OF THE FOLLOWING OPTIONS:*

I ACCEPT the terms of the above "Media Release" paragraph.I DO NOT ACCEPT the terms of the above "Media Release" paragraph (selecting this option does not affect or invalidate the remaining paragraphs of this Agreement).

6. Governing Law. I expressly agree that this Agreement is intended to be as broad and inclusive as permitted by the laws of the state of Ohio, and that this Agreement will be governed by and interpreted in accordance with the laws of the state of Ohio without giving effect to its conflict of laws rules. I agree that in the event that any clause or provision of this Agreement is held to be invalid by any court of competent jurisdiction, the invalidity of that clause or provision will not affect the remaining provisions of this Agreement, which will continue to be enforceable. I agree that the sole and exclusive jurisdiction and venue for litigation pertaining to this Agreement will be a state or federal court having jurisdiction over Hamilton County, Ohio.

I HAVE CAREFULLY READ THIS AGREEMENT AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT THIS IS A CONTRACT AND A GENERAL RELEASE OF ANY LIABILITY BETWEEN MYSELF AND CLOVERNOOK. I SIGN THIS AGREEMENT OF MY OWN FREE WILL. BY SIGNING THIS AGREEMENT, I CERTIFY THAT I AM AT LEAST EIGHTEEN YEARS OF AGE.

To express my understanding of this Agreement, I sign here:

Signature*

Date*

Date

Participants' Names (Please list all children and adults who are participating in the event.)*

Parent/Guardian Name if Participant is under age 18*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Email*

example@example.com