Educational Public Program

EDUCATIONAL PUBLIC PROGRAM ENROLLMENT & CONSENT FORM

Program Information

Location:   Start Date:   End Date:

Participant Information

Participant Full Legal Name:

Date of Birth:   Student ID (if applicable):

Parent / Legal Guardian Information (if participant is under 18)

Relationship to Participant:   Phone:

Emergency Contact & Medical Information

Relationship:   Phone:

Primary Care Physician:   Phone:

Program Fees & Payment

Cancellation & Refunds: The program maintains a defined refund schedule. Cancellation by the registrant less than 14 days prior to the program start date may be subject to partial or no refund to cover administrative and instructor costs. Administrative adjustments must be requested in writing and are subject to program director approval.

Acknowledgments, Assumption of Risk, Release and Indemnity

I acknowledge that participation in the program involves certain inherent risks, including but not limited to travel to and from program sites, physical activities, and interaction with other participants. I VOLUNTARILY ACCEPT THESE RISKS. I authorize program staff to take reasonable actions in the event of an emergency, including arranging medical treatment when necessary.

In consideration of being permitted to participate, I hereby release, discharge, and covenant not to sue the program organizers, host institution, instructors, volunteers, and their agents from any and all liability for any injury or loss arising out of my participation, except where caused by the willful misconduct or gross negligence of the released parties. I agree to indemnify and hold harmless the released parties for any claims arising from my actions or omissions.

Media Release: I grant permission for photographs, video, or audio recordings taken during program activities that include my likeness or voice to be used for educational, promotional, or archival purposes by the program and host institution without compensation. I understand that the program will not use recordings for commercial resale.   Consent: Yes

Participant Conduct: I agree to comply with the program's behavioral expectations and codes of conduct. The program reserves the right to remove any participant whose conduct poses a risk to others or violates program rules, and removal may occur without refund in cases of serious misconduct.

Accessibility & Accommodations: Reasonable accommodations will be made to enable participation by individuals with documented needs. Requesting accommodations does not guarantee immediate approval; submit documentation to program administration as early as possible.

Privacy & Recordkeeping

The program collects personal information necessary for registration, emergency response, and program administration. Personal data will be maintained in program records and shared only with authorized personnel for legitimate program purposes. By signing, I consent to the collection and processing of the data provided on this form for program administration.

Initial here to confirm you have read and understood the Acknowledgments, Assumption of Risk, Release and Media clauses: Initials:

Consent for Emergency Medical Treatment (if minor)

If the participant is a minor, by signing below I authorize program staff to obtain emergency medical treatment for my child if I cannot be reached, including transport to a medical facility. I agree to be financially responsible for any such treatment costs not covered by insurance.   I consent: Yes

Certification

I certify that the information provided on this form is true and complete to the best of my knowledge. I understand that falsification of material information may result in dismissal from the program and forfeiture of fees.

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