Student EDA Activity

STUDENT EDA ACTIVITY

Program/Activity Name:

Student Information

Parent / Guardian Contact (if student is minor)

Activity Details

Location:

Scheduled Start Date:    Scheduled End Date:

Meeting Times / Frequency:

Eligibility and Academic Information

Student currently meets prerequisites for participation: Yes

Medical Information & Emergency Authorization

Primary Care Physician: Phone:

Health Insurance Provider: Policy Number:

In the event of an emergency, and if I cannot be reached, I authorize school officials and authorized medical personnel to provide or arrange necessary emergency medical treatment for the student named above: I consent

Transportation & Field Logistics

Transportation arrangements (select all that apply):

School vehicle or contracted bus    Parent / guardian transport    Public transportation    Student walks / independent

Media, Data Collection & Privacy

I authorize the use of photographs, video, or audio recordings of the student for educational, promotional, or archival purposes under the following conditions: use is related to the educational program, individual student identity will not be published with sensitive personal information, and recordings may be retained by the school or program for a reasonable educational purpose.

Photo/Recording Release: I consent    I do not consent

Educational data collection for program assessment (aggregated or de-identified reporting): I consent    I do not consent

Code of Conduct & Attendance

By signing below, the signer acknowledges and agrees that the student must comply with all applicable school rules, program policies, and supervisor directions while participating in the activity. Failure to comply may result in dismissal from the activity without refund and notification to the student's school.

Attendance and participation are required as described in the activity syllabus. Excessive unexcused absences or uncompleted assignments may affect the student's eligibility to continue.

Acknowledgment of Code of Conduct: I acknowledge and agree

Fees, Payment & Refunds

Fee Amount (if applicable):

Payment Arrangement: Full payment    Installment plan requested    Financial aid / scholarship applied

Refund Policy: Fees are refundable only in accordance with the program's written refund schedule. The program reserves the right to cancel the activity; in such cases, eligible refunds will be processed in accordance with program policy.

Liability, Release & Certification

Assumption of Risk and Release: The signer acknowledges that participation in the activity may involve inherent risks, including physical injury. To the fullest extent permitted by law, the signer releases, indemnifies, and holds harmless the school district, program organizers, volunteers, employees, and affiliated entities from any and all liability, claims, demands, or causes of action arising out of or related to participation, except for willful misconduct or gross negligence.

Indemnification: The signer agrees to indemnify the school and its representatives against any claims, liabilities, costs, or expenses (including reasonable attorneys' fees) arising from the signer's or student's negligent or intentional acts in connection with the activity.

Certification of Accuracy: The signer certifies that all information provided on this form is true and complete to the best of their knowledge and understands that submitting false information may result in removal from the activity.

Emergency Contact Name: Phone:

Additional Notes or Accommodations:

Acknowledgment & Consent

By signing below, I acknowledge that I have read and understand the terms set forth in this Student EDA Activity form, including the liability release, medical authorization, code of conduct, and data use statements. I grant permission for the student to participate in the described activity under the conditions indicated.

If the student is age 18 or older, the student should sign. If under age 18, a parent or legal guardian must sign.

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