Nebraska Academic Decathlon

NEBRASKA ACADEMIC DECATHLON

STUDENT REGISTRATION FORM

I, (PLEASE PRINT OR TYPE) ______

First Middle Last

now a student at ______HighSchool inGrade ____

and living at ______

Number Street Apt. #

( )

CITY ZIPTELEPHONE #E-MAIL ADDRESS

Name(s) of parent(s)/guardian(s): ______

E-mail address of parent/guardian: ______

hereby request participation in the Academic Decathlon Competition at the Regional level on January 20, 2018 and at the State level on February 16-17, 2018(if applicable). My parent/guardian, whose signature is shown below, and I hereby agree tofollow the Competition Day rules and will accept the interpretations and decisions of the Competition Day Chairperson. In consideration of my participa- tion in the Decathlon, my parent/guardian and I hereby grant to the United States Academic Decathlon, Inc., its state and local affiliates, & their respective licenses, successors and assignees(collec-tively “the Grantees”), the right to publish, use & copyright my name, voice, portrait, picture, biographical material and educational data, including without limitation my test results, in all media inconnection with the promotion/publicity for the Decathlon, or for other educationalpurposes in the discretion of the Grantees. We hereby release and agree to indemnify the Grantees from and against any and all liability arising out of the exercise of the rights granted by this release.

______

Signature of Student

______

Signature of Parent/Guardian Month Day Year

NOTE TO STUDENT AND PARENT/GUARDIAN:

The Nebraska Academic Decathlon Program is required to use this form by the United States Academic Decathlon. Your test scores, identified specifically by your name, are only provided to your coach. We do announce either perfect or near perfect test scores on a given event at the Awards Ceremony. Since we invite the media to the competition, your picture may be taken and used in the news coverage of the competition.

If a student earns a scholarship, either the College Student Number(this is preferred) or the SocialSecurity Number is needed to process any scholarship earned from participating in the decathlon. All regular team members of the 1st, 2nd, and 3rd place teams at each Regional and the State Final will earn a scholarship. The amount of the scholarship is dependent on our fund raising efforts and each recipient is notified of the amount(by letter) during the early part of July. A studenthas two years following his/her graduation from high school to claim the scholarship. A scholarship check is sent directly to the college/university selected by the student & will be written to BOTH the student and the college/university. Thus, the student will know when the scholarship check arrives because he/she will be called to endorse the check.