2019 STEM Girls Rock - Girls Day Out

July 26, 2019
8:30am to 4:00pm
Please fill out the form below to apply for the Naval Information Warfare Center (NIWC) Atlantic 2019 STEM Girls Rock - Girls Day Out at Norfolk State University
First Name of Student Attending *
Your answer
Last Name of Student Attending *
Your answer
Grade Level Fall 2019 *
School District Student is Enrolled in *
Name of Middle/High School Student Will Attend this Fall *
Your answer
First Name of Guardian *
Your answer
Last Name of Guardian *
Your answer
Home Address *
Your answer
Guardian's Cell Phone Number *
Your answer
Guardian's E-mail Address *
Your answer
Emergency Contact *
(Name and Phone Number, other than Guardian)
Your answer
Essay *
(Insert 200-250 word essay below on on why student is interested in STEM, including which part of STEM student is most interested in and why, and how student thinks getting involved in STEM will benefit him/her in the future).
Your answer
Lunch Information
Lunch will be provided - Please identify any allergies/restrictions/special food needs in the comments section below.
Are there any dietary restrictions or special needs? *
Your answer
Disclaimer and Consent
Disclaimer and Consent
This activity may present the risk of injury. This exculpatory release confirms that the participant who electronically signs below accepts all aspects of that risk.
1. I, the undersigned parent/guardian, hereby voluntarily expressly and affirmatively execute this agreement in return for permission for my child to participate in the STEM Girls Rock Girls Day Out event to take place on July 26, 2019. I fully understand and appreciate the dangers, hazards, and risks inherent in the activity, which dangers include but are not limited to personal injury or death as a result or accident, act of God, or physical exertion or damage to personal property.
2. Knowing the dangers, hazards, and risks of such activities, and in consideration of being permitted to participate in the activity, I, the undersigned, agree to assume all the risks and responsibilities surrounding participation in the activity, and in advance release, waive, forever discharge, and covenant not to sue Naval Information Warfare Center (NIWC) or Norfolk State University (NSU), its governing board, officers, agents, employees, and any students acting as employees and/or volunteers(hereafter called the ‘Releasees’), from and against any and all liability for any harm, injury, damage, claims, demands, actions, causes of action, costs, and expenses of any nature that I may have or that may hereafter accrue to me, arising out of or related to any loss, damage, or injury, including but not limited to suffering and death, that may be sustained by me or by any property belonging to me, whether caused by the negligence or carelessness of the Releasees, or otherwise, while in, on, upon, or in transit to or from the premises where the activity, or any adjunct to the activity, occurs or is being conducted.
3. I understand and agree that Releasees are granted permission to authorize emergency medical treatment, if necessary. I understand and agree that Releasees assume no responsibility for any injury or damage which might arise out of or in connection with such authorized emergency medical treatment.
4. It is my express intent that this release and hold harmless agreement shall bind myself, the participant, the participant’s family, estate, heirs, administrators, personal representatives, or assigns and shall be deemed as a ‘Release, Waiver, Discharge and Covenant’ not to sue the above- named Releasees. I further agree to save and hold harmless, indemnify, and defend Releasees from any claim by me or my family, arising out of participation in the STEM Girls Rock Girls Day Out event.
5. In electronically signing this Release, I acknowledge and represent that I have fully informed myself of the content of the foregoing waiver of liability and hold harmless agreement by reading it before I sign it, and I understand that I sign this document as my own free act and deed; no oral representations, statements, or inducements, apart from the foregoing written statement, have been made. I further state that I am at least 18 years of age and fully competent to sign this agreement; and that I execute this release for full, adequate, and complete consideration fully intending to be bound by the same. I further state that there are no health-related reasons or problems which preclude or restrict the participating minors’ participation in this activity, and that I have adequate health insurance necessary to provide for and pay any medical costs that may be attendant as a result of injury.
6. I further agree that this Release shall be construed in accordance with the laws of the COMMONWEALTH OF VIRGINIA. If any term or provision of this Release shall be held illegal, unenforceable, or in conflict with any law governing this Release the validity of the remaining portions shall not be affected thereby.
I have read the above liability release statement and fully understand and accept all aspects of that risk.

Media Release:
I, guardian of the student participant, do hereby give NIWC and NSU, their assigns and legal representative the irrevocable right to use any photograph or video images of myself and my student participant in all forms and media for education or other lawful purposes in its publications and displays. I waive my right to preview or approve the finished product, including written copy that may be created in connection therewith. I understand no fee will be paid to me now or in the future. I have read this release and understand its contents.

CONSENT as the parent and/or guardian of the minor named above, I have the legal authority to execute the above release. I approve the foregoing and waive my rights in the premise. I have read the above photo permission statement and accept the terms of this statement.

Media Consent *
Guardian Consent *
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