STEM Computer Coding Program Registration

Sessions kickoff January 30, 2020

*Participant Name:

Age:

Birth Date:

Gender:

Grade:

*Participant Email:

Address:

Apt:

City:

ST:

Zip:

*Parent/Guardian Name:

*Phone:

*Parent/Guardian Email:

Emergency Contact Information

Please give the name, address, and phone number of an emergency contact that may be notified in case of emergency or illness, when parents or guardians are not available. Please provide a telephone number where these people may be reached during program hours.

Emergency Contact Name:

Relationship:

Phone:

Email:

Program Location - Please check the location in which you are registering

Note:  All training is currently online/virtual, however, please select your physical preference.

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Student Pathway and Experience/Skill Level

Note:  Our goal is to train "ALL" students no matter their experience.  Indicating experience helps to align students to the "right" pace of training.

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Affiliations / How did you hear about our program?

Select all that apply:

I hereby release and discharge, and by these presents do for myself, my heirs, executors, administrators and assigns release and forever discharge BDPA, STEAMsport, Inc. , H.J. Russell and Company, and their respective members, employees, contractors, agents and representatives, of and from all claims, demands, damages, actions, causes of action or suits at law or in equity, of whatsoever kind or nature which I now have or may have hereafter, for or because of any matter or thing done, omitted, or suffered to be done by said entities prior to and including the date hereof, and particularly on account of all injuries both to person and property resulting, or to result, from participation in programs and activities sponsored by discharge BDPA, STEAMsport, Inc. , H.J. Russell and Company, and their respective members, employees, contractors, agents and representatives.

 

Additionally, I hereby grant to BDPA, STEAMsport, Inc., H.J. Russell and Company my absolute and unconditional permission to use, without charge, any and all photographs, video reproductions or other like kinds of imagery production taken during the event in which l or my likeness or image, or the likeness or image of my child or ward, may appear as the subject matter for publicity or any other purpose. I understand that my name or the name of my child or ward may be included with the photograph or other image.

 

The intent of this release is not to sell or publicize individual images of the parents or children attending this program. It is intended to make you aware that these images may appear with others or in groups on brochures, internal publications, or press releases.

 

IN WITNESS WHEREOF, the undersigned hereby executes this release.

*Parent/Guardian Signature:

*Indicates a required field.

Date:

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