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STEMblazers at Campbell University
This form will serve as your registration to participate in STEMblazers at Campbell University on February 10, March 9, and April 13. 
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Email *
Student Full Name [First Last] *
Student preferred email *
Please share your cell number so we can text you about opportunities that may come up. We promise not to spam you!
Grade (at time of registration) *
Anticipated year of High School Graduation *
Birthdate *
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Ethnic Background *
Required
Gender Identity *
Unisex T-shirt size
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STEMblazers will provide a lunch on the meeting days - do you have any food allergies we should be aware of? *
Do you have any medical needs we should be aware of (i.e. epilepsy/seizures, timed meds, etc.)? If so, you will receive a follow-up email to discuss the best course of action in the event an instance occurs. 

Please note: STEMblazers staff and volunteers cannot administer medication to students. Students must be able to manage their meds independently. 
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Guardian 1 Name [First Last] *
Guardian 1 Email *
Guardian 1 Phone Number (In case of emergency) *
Guardian 2 Name [First Last]
Guardian 2 Email
I give my child permission to join this chapter and confirm that the above information is true and accurate. [Guardian Signature] *
PHOTO & VIDEO RELEASE *
I hereby grant STEMblazers and its respective affiliates, licensees, subsidiaries, successors, assigns, and agents a perpetual, worldwide, non-exclusive, royalty-free right and license to use, copy, process, adapt, transmit, reproduce, create derivative works from, modify, publish, edit, translate, distribute perform, display and sublicense my image, likeness or the sound of my voice as captured as a still image or video, in a photograph or through any other means. I agree that such images of me or the sound of my voice may be used in perpetuity in any and all publications, including website entries or any other media, without payment or any other consideration. I understand and agree that these materials will become the property of STEMblazers and will not be returned. I hereby irrevocably authorize STEMblazers to edit, alter, copy, exhibit, publish or distribute my still image or video image or likeness or the sound of my voice for purposes of promoting STEMblazers's mission, publicizing the images or for any lawful purpose. In addition, I waive the right to inspect or approve the finished product, including written or electronic copy, wherein my image or likeness or sound of my voice appears. I also waive any right to royalties or other compensation arising or related to use of my still or video image or likeness or sound of my voice. I hereby hold harmless and release and forever discharge STEMblazers including without limitation, its employees, officers, representatives, shareholders, successors-in- interest or agents, from all claims, demands and causes of action which I, my heirs, representatives, executors, administrators, or any other person acting on my behalf or on behalf of my estate have or may have by reason of this authorization and release. I acknowledge that this agreement constitutes the entire agreement between myself and STEMblazers and concerning the subject matter hereof, and supersedes any prior or contemporaneous understandings, agreements or representations. I understand that no supplement, modification or waiver of this agreement shall be binding unless executed in writing by both myself and STEMblazers. I agree that this agreement shall be construed without regard to any presumption or rule requiring construction or interpretation against the party drafting or causing any instrument to be drafted. I hereby certify that I am the parent or guardian of the student named above, and do hereby give my consent without reservation to the foregoing on behalf of this person. *
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STEMBLAZERS TRANSPORTATION AWARENESS CONSENT & RELEASE *
When public transportation is not available, it is the student’s parent’s / guardian’s responsibility to provide or arrange for their student’s transportation to and from the event. When alternative forms of transportation are utilized, the STEMblazers does not assume any responsibility for the safety, training of drivers, condition of vehicles, adequacy for the use or purpose intended, or any other matters related to transportation. Therefore, we, the undersigned parent / guardian and student, hereby acknowledge, agree, and understand that the STEMblazers does not insure, endorse, approve, or sponsor any form of non-school transportation, whether by parents, students or otherwise, to and from activities and events. We further acknowledge it is our responsibility to provide or arrange for our/my child’s transportation to STEMblazers events when public transportation is not available. As such, we consent to our child’s use of alternative forms of transportation, including private vehicles driven by parents, and, if applicable, consent to our child’s use of a vehicle to transport himself/herself to events. We hereby waive, release, discharge, and agree to hold harmless and indemnify STEMblazers, its agents, employees, and insurers, from any claim, cause of action, damage, injury, or demand of any nature, including bodily injury, property damage or death, arising from or sustained during or as a result of my/our child’s utilization of or participation in any STEMblazers event, whether furnished by us, our student, another student, parent or otherwise.
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CODE OF CONDUCT *
Download our Code of Conduct, read, and sign below. http://bit.ly/2ra397y I hereby confirm that I have read, understood, and will abide by STEMblazers' Code of Conduct.
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We understand committing to something new comes with some Q&A. We invite you to join us before our first session for an information session followed by Q&A. This is also a great time to invite your friend who might be on the fence.

January 25th 6P-7P Virtually on Google Meets
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