Student STEM Outreach Form

Student STEM Outreach Form

Program Details

Program Name:     Session Date(s):

Location:

Sponsor Organization:     Contact Phone:

Student Information

Student Name:

Date of Birth:     Student ID (if applicable):

Parent / Guardian Information (if student is a minor)

Emergency Contact

Health Information & Medical Consent

Does the student have any allergies, chronic conditions, or medical considerations that program staff should be aware of?    Yes    No

Consent for emergency medical treatment: I authorize program staff or representatives to authorize emergency medical care, which may include transport to a medical facility and treatment by qualified personnel, if I cannot be reached.

Medical Insurance Provider: Policy/ID #:

Participation & Conduct

Code of Conduct Acknowledgment: I acknowledge that the student must follow all program rules and staff directions. Unacceptable behavior, including harassment, physical aggression, theft, or unsafe conduct, may result in removal from the program without refund.

I agree to the code of conduct:    I agree

Transportation

Transportation by program staff or volunteers:    Authorized    Not authorized

If authorized, I understand that staff will exercise reasonable care but are not insurers of the student’s safety during transport.

Media, Privacy & Data Use

Media Release: I grant permission for photographs, video, and audio recordings of the student taken in connection with the program to be used by the sponsor organization for educational, promotional, or reporting purposes, in print and electronic media, unless I decline below.

   Grant media release    Decline media release

Data Collection: I understand that the program may collect minimal academic and demographic information to assess program outcomes. Collected data will be stored securely and used only for program administration and evaluation unless separate consent is obtained.

Liability Release and Indemnification

In consideration of the student’s participation, I, on behalf of the student and myself, release and hold harmless the sponsor organization, its officers, employees, volunteers, and agents from and against any and all claims, liabilities, damages, costs, and expenses arising out of or related to the student’s participation, except to the extent caused by gross negligence or willful misconduct of the sponsor organization. This release includes, but is not limited to, claims for personal injury, property damage, and wrongful death.

Indemnification: I agree to indemnify and defend the sponsor organization against any claims arising from my willful acts or omissions.

Accessibility & Special Accommodations

If the student requires special accommodations to participate fully, please describe the accommodation needs below. The program will make reasonable efforts to provide accommodations consistent with available resources.

Acknowledgment and Certification

By signing below I certify that I am the student if 18 years of age or older, or the parent or legal guardian of the student named above. I attest that the information provided on this form is true and complete to the best of my knowledge. I have read and understand the program policies, consent to the terms set forth herein, and acknowledge that I have authority to sign on behalf of the student.

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