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STEM2020 REGISTRATION
Please fill out a separate form for each of your children
Parent/Guardian Name: *
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Parent/Guardian Email: *
Your answer
Parent/Guardian Phone: *
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Student Name: *
Your answer
Address: *
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Student Age: *
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Student Birthdate: *
Your answer
What school does your child attend? *
Your answer
Which site will your child attend? *
How did you hear about us? *
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Does your child have any special needs? (religious, allergies, behavioral issues, etc.) *
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Can your child swim? *
Do You Receive Illinois Action for Children? *
Are you ableto receive assistance from CEDA? *
Are you able to receive assistance from The Housing Authority? *
Emergency Contact: *
If your child becomes ill or is injured while attending STEM2020 and parent/guardian cannot be contacted, the following people have permission to be contacted and released to: (Below Give: Names, Relationship, and Phone Numbers)
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Program Waivers and Release of All Claims and Assumption of Risk
Program Waiver and Release of All Claims and Assumption of Risk Warning of Risk: Recreational programs are intended to challenge and engage the physical, mental, and emotional resources of each participant. Despite careful and proper preparation, instruction, medical advice, conditioning, and equipment, there is still a risk of serious injury when participating in any recreational program. Understandably, not all hazards and dangers can be foreseen. Depending on the particular activity, participants must understand that certain risks, dangers, and injuries due to inclement weather, slipping, falling, poor skill level or conditioning, carelessness, horseplay, unsportsmanlike conduct, premises defect, inadequate or defective equipment, inadequate supervision, instruction or officiating, and all other circumstances inherent to indoor, outdoor, and water related recreational programs exists. In this regard, it must be recognized that it is impossible for Adults Active in Youth Development/STEM2020 to guarantee absolute safety.

Waiver and Release and Assumption of Risk: Please read this information carefully and be aware that in registering for and participating in this program, you will be expressly assuming the risk and legal liability and waiving and releasing all claims for injuries, damages or loss which you or your minor child/ward might sustain as a result of participating in any and all activities connected with and associated with this program (including transportation services, be it field trip, other associated program sites, to or from home, or any other transportation provided). I recognize and acknowledge that there are certain risks of physical injury to participants in this program and I voluntarily agree to assume the full risk of any and all injuries, damages or loss, regardless of severity, that my minor child/ward or I may sustain as a result of said participation. I further agree to waive and relinquish all claims I or my minor child/ward may have (or accrue to me or my child/ward) as a result of participating in this program against Adults Active in Youth Development, Inc./STEM2020, including its officials, associates, agents, volunteers, and employees (hereinafter collectively referred to as "AAYD/STEM2020").

Aquatics: I specifically recognize and acknowledge that there are certain inherent risks of physical injury to patrons of aquatic activities, and I voluntarily agree to assume the full risk of any injuries, damages or loss, regardless of severity that my minor child/ward or I may sustain as a result of participating in any and all activities and programs connected with or associated with use of aquatic facilities or activities. I further recognize and agree that lifeguards and other aquatic staff are not responsible for supervising my activities or the activities of my minor child(ren) and I agree that I am solely responsible for assessing whether my child(ren) are physically fit and/or adequately skilled for aquatic activities.

Release: I do hereby fully release and forever discharge Adults Active in Youth Development, Inc./STEM2020 from any and all claims for injuries, damages or loss that my minor child/ward or I may have or which may accrue to me or my minor child/ward and arising out of, connected with, or in any way associated with this program. Photo/Video Policy and Warning: Photos and video footage are periodically taken of people participating in the programs or activities, attending a class or event, or using any facilities or property used by Adults Active in Youth Development, Inc./STEM2020. Please be aware that by registering for a program or class, participating in an activity, attending an event, or using any of these facilities or property, you authorize this organization to use these photos and video footage for promotional purposes in publications, advertising, marketing materials, brochures, event flyers, social media (including Facebook, YouTube, Instagram, Twitter, and other social media sites), and the organization’s website without additional prior notice or permission and without any compensation to you. All photos and videos are property of Adult’s Active in Youth Development, Inc.

Food and/or Beverage Consumption Waiver: I do hereby fully release and forever discharge Adults Active in Youth Development, Inc./STEM2020 and affiliates from any and all claims and any or all risk of personal injury, illness or death arising out of or resulting from consumption of food items provided by Adults Active in Youth Development, Inc./STEM2020 and discharge them and their respective owners, directors, officers, partners, employees, and agents (hereafter referred to collectively as the "Releasees") from any and all claims, liabilities, damages, losses, or other expenses of any nature whatsoever for any personal injury, illness, or death (collectively, “claims") arising out of or resulting from the consumption of the food items provided. This indemnity obligation shall also include reasonable attorneys' fees, investigation costs, and other costs and expenses incurred by Releasees with respect to any claims made against Releasees. The Permittee agrees to indemnify and hold the Releasees harmless from any claims released above or incurred by the Releasees in defending against any claims or liabilities released above. It is understood and agreed that this Waiver of Liability, Assumption of Risk and Indemnity Agreement shall not be construed as an admission of liability, and that any such admission is hereby expressly denied.

By registering for this activity I have read and fully understand the above, warning of risk, assumption of risk, waiver and release of all claims, food and/or beverage consumption waiver, and photo/video policy and warning. If registered online, my online signature will be substituted for and have the same legal effect as an original hard copy signature. PARTICIPATION WILL BE DENIED if the signature of adult participant or parent/guardian and date are not included.
E-signature and date below : *
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