Student Summit Registration Form

STUDENT SUMMIT REGISTRATION FORM

Event Information

Summit Name:   Date(s):   Location:

Student Information

Date of Birth:   Student ID:   Grade/Program:

Primary Contact (Parent / Guardian if Minor)

Phone:   Email:   Relationship:

Emergency & Medical Information

Phone:   Relation:

Insurance Provider:   Policy #:

Program Selection & Preferences

Select workshops and sessions you wish to attend (space may be limited):

Leadership Lab STEM Innovation Arts & Design Civic Engagement

Fees & Payment

Registration Fee: $   Discount Code (if applicable):

Payment Method: Credit Card Check Purchase Order / School Invoice

Acknowledgements, Release, and Emergency Authorization

By submitting this registration, I certify that the information provided is true and accurate. I understand that participation in the Student Summit includes educational activities that may involve travel on foot and group sessions. I acknowledge the inherent risks of participation and voluntarily assume full responsibility for any injury, loss or damage that may occur as a result of participation, except to the extent caused by the gross negligence or willful misconduct of the summit organizers.

I authorize event staff and affiliated medical personnel to secure emergency medical treatment for the student named on this form if required and to consent to such treatment on behalf of the student if I cannot be reached. I agree to be financially responsible for any such treatment.

I agree to indemnify and hold harmless the summit organizers, host institutions, volunteers and their officers, employees and agents from any claims, liabilities or expenses (including reasonable attorneys' fees) arising from my participation or my child's participation, except to the extent caused by the organizer's gross negligence or willful misconduct.

Photo/Media Release: I grant permission for photographs, video and audio recordings of the registrant to be used by the summit for promotional, educational and archival purposes without compensation.

Code of Conduct: I have read, understand and will comply with the Student Summit code of conduct and behavioral expectations.

Cancellation & Refund Policy: Registrations cancelled in writing more than 30 days before the summit start date will receive a refund less an administrative fee. Cancellations within 30 days are not eligible for refund except for documented emergency. The summit reserves the right to cancel or reschedule; in such case the registrant's sole remedy is a full refund of registration fees.

Privacy & Data Use

Personal information provided on this form will be used solely for event administration, safety, and communications related to the Student Summit. The summit will take reasonable steps to protect personal data and will not sell personal data to third parties. By registering you consent to the collection and use of the information for these purposes.

Special Authorizations (if applicable)

For students under 18 years of age, a parent or legal guardian must sign below. Check the box if the registrant is under 18: Registrant is a minor

If the student requires the administration of medication during the event, a separate medication administration form and physician authorization may be required. The summit will follow on-site medication policies where applicable.

Sign Now