WHAT IS DESTINATION IMAGINATION?

  • Destination Imagination (DI) is an international, educational program that gives students an amazing outlet for their creativity, while teaching them leadership, teamwork, positive thinking, project management and so much more.
  • Teams of 2 to 7 kids from Kindergarten thru University level solve one of the following open-ended Challenges.

  • Teams present their solutions at a Regional Tournament at Piqua City Schools Feb. 24, 2018.
  • Winners in grades 3 thru University level, advance to the State Tournament, and winners at the State Tournament move on to Global Finals to compete against more than 1,400 teams from around the world.
  • There’s even a noncompetitive Rising Stars category with a special Challenge for K-2nd grade.
  • Teams also solve an on-the-spot Instant Challenge at the tournaments, where they must think quickly on their feet and work together to solve a problem in around five minutes.

Sign up by completing this application and attaching a check for $50.00 made out to Tipp Monroe Community Services

TIPP MONROE COMMUNITY SERVICES, INC.

REGISTRATION FORM

Activity:Destination Imagination Fee $50.00Paid______

Student’s Name: Last ______First______

Address ______City______Zip______

Have you been on a DI team before?____YES _____NO If so , who was the team manager?______

Circle one: Tipp City Resident Monroe Township Resident Non-resident

Age: ______Grade: ______Name of Parent or Legal Guardian ______

Home Phone ______Work Phone: ______

E-mail address: ______Cell: ______

The above enrollee or legal guardian of said enrollee in consideration of the activity indicated hereby releases and

dischargesTipp Monroe Community Services, Inc., the City of Tipp City, the Monroe Township Trustees, and the Tipp City

Exempted Village School Board of Education and their assignees from any liability whatever, and will hold them harmless

from any judgment brought against them.

*Please note that photos taken at TMCS classes may be used in the Community Connection or other publications.

Date ______Signature______

Parent/Legal Guardian

OVER FOR MEDICAL RELEASE (UNDER 18 YEARS)

TIPP-MONROE COMMUNITY SERVICES, INC. EMERGENCY MEDICAL AUTHORIZATION

PART I GRANT TO CONSENT

PURPOSE: To enable parents to authorize emergency treatment for children who become ill or injured while under TMCS authority, when parents cannot be reached.

NAME: ______AGE: ______

(Participant’s) Last First

Contact Person: ______Phone: ______

Alternate Contact: ______Phone: ______

Emergency Contact: ______Phone: ______

Preferred Doctor: ______Phone: ______

Preferred Dentist: ______Phone: ______

Preferred Hospital: ______Phone: ______

In the event reasonable attempts to contact the parents or guardians have been unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed necessary by preferred Dr. (s), or preferred Dentists or in the event designated Dr. or Dentist is not available, by another licensed physician or dentist; and (2) the transfer of the child to preferred hospital or any hospital reasonably accessible.

NOTE: This authorization does not cover major surgery unless the medical options of the two other licensed physicians or dentists, concurring in necessity for such surgery are obtained BEFORE the surgery IS PERFORMED.

Medical History:

Allergies: ______

Medications: ______

Physical Impairments: ______

Date______Signature: ______

Parent or Legal Guardian

Date & Initial ______Date & Initial ______Date & Initial ______

Part II REFUSAL OF CONSENT

Do not complete if you completed Part I

I do NOT give consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment, I wish that Tipp-Monroe Community Services to take no action or to______

______

Date: ______Signature: ______

Parent or Legal Guardian