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Organization Name and Program Title
Registration Form
Participant Information:
Participant's Name:
Address (City, State, Zip):
Home Phone:
Birthdate:
School Name:
School District:
Child’s school grade:
Gender:
Ethnicity (Please select):
 Hispanic or Latino
 Non-Hispanic or Latino
Race (Check as many that apply):
 Black or African American
 Asian/ Asian-American
 American Indian or Alaskan Native
 Native Hawaiian or Pacific Islander
 White or European American
 Other:
Please list parent/ guardian contact information in this section. Please make sure
at least two phone numbers are listed.
Name:
Relationship:
Address (City, State, Zip):
E-mail Address:
Home Phone:
@
Work:
Cell:
Please list one emergency contact other than the parent/guardian. Please make
sure at least two phone numbers are listed.
Name:
Home Phone:
Relationship:
Work:
Cell:
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Liability Waiver and Release
As the parent or guardian, I have the authority to make legal decisions for the benefit of
my child. I hereby assume all risks of property loss and personal injury, including death
that may result during program activity. I do hereby release the State of Iowa; Board of
Regents, State of Iowa; The University of Iowa, and their employees and agents from
any and all liability as a result of my child’s participation, except to the extent that such
liability is a direct result of The University of Iowa’s negligent acts or omissions. I
understand and appreciate the inherent risk of participating in the program activities. By
signing below, I certify that I have read this release of liability, fully understand it, freely
and voluntarily sign it, and I am acting for myself, my child, my heirs, personal
representatives and assigns in doing so. I agree to indemnify and hold harmless the
State of Iowa; The University of Iowa; Board of Regents, State of Iowa and their
employees, agents and representatives whether injury is caused in whole or in part by
the fault of my child’s negligence or the fault or negligence of any third party.
Print Name
Signature
Date
Photo, Video, Audio, and Information Release
I, the undersigned, hereby consent to allow for my child to be photographed and his/her
image and/or voice to be recorded. I hereby grant to the University of Iowa the rights to
use my child’s image, voice, name and/or likeness in any medium whatsoever for the
purpose of promoting the University of Iowa or any of its units without any payment to
me. I hereby expressly waive any rights of action I may have and release the State of
Iowa; Board of Regents, State of Iowa; The University of Iowa, and their employees and
agents from any and all liability arising out of or in connection with the use of such
image, voice, name and/or likeness, including, but not limited to, any claims for any
violation of any personal or proprietary right. The University, its successors and assigns
shall own all right, title and interest, including without limitation the copyright, to any
such photograph, video-recording, and/or audio-recording.
Print Name
Signature
Date
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Misbehavior Policy
If a child misbehaves, the program mentor and child will sit and discuss the child’s
unacceptable behavior, this will be done only two times. If the child continues to be noncompliant to the requests of the staff from the University of Iowa, we will notify the
parents. At that time, we will ask for that child to be removed from the program. We
want to create a conducive learning environment for all students, and program to feel
safe.
Print Name
Signature
Date
Health Information:
The University of Iowa and the College of Engineering rely on your disclosure of health
information. Failure to provide us with this information necessary for appropriate
accommodation in a timely fashion may result in the student’s inability to participate in
the program. The University of Iowa and the College of Engineering reserves the right to
cancel or terminate any student’s participation on that basis. In addition, neither The
College of Engineering; The University of Iowa; The State of Iowa the Board of Regents;
nor their respective employees and agents shall be liable for any damages or liability
resulting in whole or in part from misrepresentations or nondisclosures regarding any
student’s health information.
 Yes, I agree to these terms
 No, I do not agree to these terms
Signature
Date
Physical, Dietary, or Medical Restrictions
Does the participant have any physical, dietary (food allergies) or medical restrictions
for which special accommodations should be made?
 No, my child is free of restrictions
 Yes, my child has the following restrictions:
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Health Mandatory Release
Except as stated within this application, this individual is in good health and capable of
participating in this program. In case of emergency, I authorize the University of Iowa,
College of Engineering, when neither parent/guardian can be contacted by phone, to
arrange for emergency medical treatment; to take my child to the emergency room of
the nearest hospital, at my expense; and to sign a permit on my behalf for the
administration of a general anesthesia by a qualified anesthesiologist. The hospital has
my authorization to provide treatment that a physician deems necessary for the wellbeing of my child.
 Yes, I agree to these terms
 No, I do not agree to these terms
Signature
Date
Notification of Alternative Transportation Arrangements
I,
(Name of Parent/ Legal Guardian) give
my permission for
(Son/ Daughter) to:
Be transported by private vehicle to and/or from this program, or dropped-off
and/or picked-up by another parent, relative or family friend.
Name of carpool driver(s)/ drop-off & pick-up person(s)
Be dropped off and/or picked up curbside as I will be picking them up, therefore
my child can sign themselves in and/or out.
Walk or use public transportation to go home, therefore my child can sign
themselves in and/or out.
I hereby release, discharge and indemnify the University of Iowa, its administration,
staff, employees, officers, directors, volunteers, insurers, agents, and representatives
from any and all claims, causes of action, liability or damages arising out of, or relating
to the transportation of my child.
Signature of Parent/ Legal Guardian
Date