The Selected Participants Will Attend the Program According to the Following Schedule

REGISTRATION FORM

The selected participants will attend the program according to the following schedule:

Program runs June 27th through July 22nd - Monday through Friday, 9:30 am – 3:30 pm

Participation in the program is voluntary. If your child is selected, he is expected to attend every day for the full four weeks. This packet contains the forms that must be completed and returned before the student will be allowed to attend summer program.

Student Information
Parental Consent, Release, Hold Harmless and Authorization To Reproduce Physical Likeness
Verizon General Release From
Program Evaluation and Research Release Form
Participant MedicalRelease Form
Field Trip Release Form –(A Field Trip Release Form will be provided prior to the date of the field trip)

Please make sure that all five forms are completed and returned to us by June 15th. Completed forms may be mailed, faxed, or email to the attention of:

Dr. James Maiden

Assistant Dean of Student Affairs

The University of the District of Columbia

4200 Connecticut Avenue, NW

Building 41, Suite 405

Washington, DC 20008

Fax: 202 274-5589

Phone: 202 274-5768

STUDENT INFORMATION

Please make sure to complete all required information and print clearly on this form. Missing information may cause delays in processing your child’s application and could cause him not to be eligible for the program.

Participant Information

First Name: ______Middle Initial _____Last Name:______

Phone: ______Email: ______

Home address______City______State___ Zip ______

School: ______Grade (as of Fall 2016): ______

Birthdate: ______

Ethnicity: (Check one) ___ Black/African American___ Hispanic/Latino

T-Shirt Size: (Check one) YouthSize: ___ SM ___ MED ___ LG

Parents/Guardian Information

Parents/Guardian First Name: ______Middle Initial ____Last Name:______

Primary contact: ______Relationship to participant: ______

Home address (If different)______City______

State ______Zip ______

Cell Phone: ______Email:______

Secondary contact: ______Relationship to participant: ______

Cell Phone: ______Email:______

I confirm that I am the Parent/Guardian of the student participating in the program:

______Parent/guardian’s name and signature Date

2. CONSENT, RELEASE, HOLD HARMLESS AND AUTHORIZATION TO REPRODUCE PHYSICAL LIKENESS

I grant permission for my son (Please Print) ______to participate in The Verizon Minority Male Makers Program summer program.

I understand that in order to participate in this program, my son must abide by the established rules and codes of conduct established by the program staff. The Verizon Minority Male Makers Program reserves the right to dismiss a child from the program due to that child's disruption of the program, failure to follow safety or program instructions, and any other disruptive behavior.

I understand and agree to assume any and all risks associated with the summer program activities. I understand that even with careful supervisions, accidents can occur. I recognize this risk and agree to release and forever discharge all the volunteers, staff and the schools where such activities take place from any and all claims, demands, damages, actions, causes of action, or suits of any kind or nature, and particularly on account of all injuries, both to person or property, at any time or any place relating to participation in the program.

______Parent/guardian’s name and signature Date

3. GENERAL RELEASE

I grant Verizon Communications Inc., its subsidiaries, successors, assigns, and licensees (collectively “Verizon”) the following rights:

1. I grant Verizon the right to take photographs and videos of me and my likeness and record or otherwise take my voice for testimonials and other statements (“Photography”) on the date and at the location listed below.

2. I also grant Verizon the right to edit and use the Photography in any way whatsoever, for any purpose, and in any manner and medium, including but not limited to, advertising, publicity or promotional material, in print, video, television, radio, or any other media, electronic or otherwise, including websites and the Internet, at any time or times throughout the world, to use quotations and soundtrack recordings of me or my voice, including the right to substitute the voice of another person(s) for my voice, to use my name or a fictitious name and biographical and other information, accurate or fictitious, concerning me in connection with the use of the Photography.

3. I waive any right to inspect or approve the Photography or how the Photography is used and further waive any claim that I may have with respect to its use.

4. I acknowledge that I will not receive any compensation other than any publicity that I may receive relating to the use of the Photography.

5. I forever release and discharge, and agree to hold harmless Verizon and its directors, officers, agents, employees, shareholders and representatives from any and all liability for any violation of any personal rights (including right of privacy and right of publicity), intellectual property rights or any other rights which I may have arising out of or in connection with Verizon’s use of the Photography

6. I represent and warrant that I am of full age and have every right to contract in my own name in the above regard. This agreement shall be binding upon me, my heirs, legal representatives and assigns.

Location and date: ______

I hereby agree and consent:

Printed Name / Signature / Address / Date

If a minor: I am the (parent/legal guardian) of the named minor. I agree and consent to the foregoing on behalf of the minor and personally join in the warranties and representations above. I also agree to indemnify and hold harmless Verizon against any claims the minor may make as a result of Verizon’s use of the Photography as described above.

Printed Name of Minor / Printed Name of
Parent/Legal Guardian / Signature of Parent/Legal Guardian / Address / Date

3. Exención de responsabilidad general

Por medio del presente, yo, el abajo firmante, otorgo los siguientes derechos a Verizon Communications Inc., 140 West Street, New York, New York 10007, sus subsidiarias, sucesores, cesionarios y concesionarios (colectivamente, “Verizon”):
Otorgo a Verizon el derecho y la autorización irrevocables y absolutos para registrar mi imagen y/o mi voz mediante fotografía fija, película, cinta de video, grabaciones de sonidos o cualquier otro medio (en adelante, “fotografía”) en la fecha y el lugar que se mencionan más adelante.
También otorgo a Verizon el derecho a editar según su criterio, usar, publicar, distribuir, exhibir, obtener dicha fotografía y otorgar licencias de ella a terceros, de manera total o parcial, individualmente o junto con otras fotografías, imágenes o cualquier material sujeto a derechos de autor, con cualquier finalidad, de cualquier manera y por cualquier medio, como materiales de publicidad, propaganda o promoción, entre otros, en forma impresa, por video, televisión, radio o cualquier otro medio de comunicación, por medios electrónicos o de otra manera, como sitios web e Internet, en cualquier momento y en todo el mundo a perpetuidad sin la obligación de informarme al respecto, a obtener derechos de autor de dicha fotografía en su propio nombre o de otra manera, a usar o autorizar el uso de citas y grabaciones de sonidos míos o de mi voz, incluido el derecho a reemplazar la voz de otra persona o de otras personas por mi voz, a usar mi nombre o un nombre ficticio e información biográfica o de otro tipo, precisa o ficticia, respecto de mi persona o relacionada con el uso de dicha fotografía.
Por medio del presente renuncio a todo derecho a revisar o aprobar la fotografía o el material editorial o impreso que pueda utilizarse junto con ellos; asimismo renuncio a cualquier reclamación que pudiera tener con respecto al uso eventual al que pudieran estar sujetos, independientemente de que yo tenga o no conocimiento del uso.
Acepto que Verizon, o los agentes de Verizon, poseen la titularidad de los derechos de autor sobre la fotografía. Si recibiera una copia impresa, en negativo o de otro tipo de dicha fotografía, no podré autorizar a ninguna otra persona a que la use.
Por medio del presente declaro y garantizo que esta asignación de derechos no contradice de ningún modo cualquier compromiso que yo tenga actualmente. Hasta la fecha no he autorizado (con una autorización que siga en vigor), ni autorizaré ni permitiré el uso de mi nombre, voz, cita, fotografía o imagen en relación con la publicidad y la propaganda de cualquier producto o servicio que pertenezca a la competencia o que sea incompatible con los productos o servicios que ofrece Verizon.
Acepto que no recibiré compensación alguna por otorgar los derechos incluidos en el presente documento.
Por medio del presente, eximo y exonero para siempre y acepto librar a Verizon y sus directores, directivos, agentes, empleados, accionistas y representantes de toda responsabilidad causada por la violación de los derechos individuales (incluido el derecho a la privacidad y el derecho a la propia imagen), los derechos de propiedad intelectual o cualquier otro derecho que pudiera tener y que surja del uso por parte de Verizon de la fotografía tal como se describió anteriormente, o esté relacionado con dicho uso, entre los que se incluyen errores, aspecto borroso, distorsión, alteración, ilusión óptica o auditiva de la fotografía.
Por medio del presente declaro y garantizo que soy mayor de edad y que tengo el derecho de celebrar el contrato con respecto a lo anterior en nombre propio. El presente acuerdo será vinculante para mí, mis herederos, representantes legales y cesionarios. Asimismo declaro que he leído esta Exención de responsabilidad general antes de firmarla y que comprendo sus términos.
Lugar y fecha: ______

Título y n.° de proyecto:______

Información y firma de la persona fotografiada:

Nombre
(en letra de imprenta) / Firma / Dirección / Fecha

En caso de ser menor de edad: Soy (el padre/la madre/tutor legal) del menor indicado a continuación. Acepto la información precedente en nombre de dicho menor y personalmente adhiero a las declaraciones y garantías expuestas anteriormente. Asimismo, acepto indemnizar y librar de toda responsabilidad a Verizon con respecto a las reclamaciones que el menor pudiera hacer como resultado del ejercicio que Verizon haga

4. PROGRAM EVALUATION AND RESEARCH RELEASE FORM

The Verizon Minority Male Makers Program evaluates all its programs to make sure that they are effective, and to improve them, as needed. The evaluations and results are reviewed by those who oversee the program. The evaluations and results may also be used for scholarly research to increase minority males’ entrance in to the STEM field.

During the time your son is in The Verizon Minority Male Makers Program, he may be observed by evaluators and researchers during different program activities and may be asked to give his feedback and opinions in response to questionnaires or surveys, in focus groups, and/or in interviews.

Your child’s participation is VOLUNTARY; he does not have to participate in these activities, and can choose not to answer certain questions, or decide not to participate, or withdraw from participation at any time.

These evaluation assessments are not anonymous, so your child’s name will be included on the forms that are used for the evaluation(s); however, all information and results will be kept strictly CONFIDENTIAL and personal data will not be stored. Information identifying your child’s name will be removed before the results are analyzed and given out. Participants’ names will never be used in any report or publication. Data shared with Verizon will be in aggregate and no individual level data (or identifying information) will be shared.

Finally, The Verizon Minority Male Makers Program reserves the right to use personal information (for example, permanent address, phone number, and/or email address) to contact participants after the program to gather information about their career or educational successes. Participants’ personal information will never be distributed outside of The Verizon Minority Male Makers Program – Directed by The University of the District of Columbia; will be kept completely confidential; will be used by authorized personnel only; and will be stored in password protected and secure servers or databases.

If you have any questions about this evaluation or about evaluation participants’ rights, please contact James Maiden, at 202 274- 5768 or .

By authorizing your child to participate in The Verizon Minority Male Makers Program, you are agreeing to the contents of this parental permission form – and indicating that you have read and understand the information above and allow your child to participate in the evaluation part of this program. When evaluation assessments are presented to participants in the program, your child will be informed about the evaluation study and about his rights as a participant. At that time your child will be asked to provide his agreement to choose to participate in the assessment.

______Parent/guardian’s name and signature Date

5. PARTICIPANT MEDICAL RELEASE FORM -A

Name of Child’s Physician______

Physician Phone ______

Medical Insurance Co. ______Policy/Group ______

Does the participant have any health conditions (i.e. allergies, chronic conditions), prescribed medications, or special circumstances (i.e. religious convictions or legal arrangements) that we should be aware of?

(Check one) ___ NO ___ YES If yes, please explain on back.

Please also list any medication(s) the participant will require (prescribed or not).

______

In the event of an emergency, when parents or emergency contacts cannot be reached, The Verizon Minority Male Makers Program has my permission to take my child to the nearest hospital. (Check one) ___ NO ___ YES

Please provide the information of a responsible adult whom we can contact in an emergency if we are unable to contact you.

______Name Relationship

Home address______City______

State ______Zip ______

Day and Evening phone (d) ______(e) ______

Email______

5. PARTICIPANT MEDICAL RELEASE FORM - B

I/We certify that the participant is in good health and hereby authorize the directors of The Verizon Minority Male Makers Program to act for me/us, according to their best judgment, in any emergency requiring medical attention. I/We understand and agree that instructors, counselors, and staff may need to contact appropriate emergency medical providers regarding said minor. I/We give consent for any medical treatment (i.e., diagnostic, therapeutic, and surgical procedures) that such medical providers may deem necessary with the understanding that the cost of any such treatment will be my/our responsibility. I/We understand that my/our consent will allow procedures to be promptly carried out so that no unnecessary delays will occur with treatment. No operation will be performed, except in extreme emergency, without me/us being contacted and fully informed and consent obtained.

______Parent/guardian’s name and signature Date

FIELD TRIP RELEASE FORM

(A Field Trip Release Form will be provided to parentsprior to the date of the field trip)

My child has permission to participate in field trips with chaperones, for summer program activities.

______Parent/guardian’s name and signature Date