2019 Open Minds, Open Doors Student Registration Form
Your daughter is invited to register for the 23rd annual Open Minds, Open Doors STEM+ conference for 7th and 8th grade girls, to be held on Thursday, October 10th, at Coe College in Cedar Rapids. The Open Minds, Open Doors conference is intended to encourage middle school girls to pursue future career fields with foundations in science, technology, engineering and math (STEM). Spaces are limited!

If you have questions regarding transportation or payment, please contact your daughter's teacher or the school personnel who will be coordinating this activity.

Thank you!
Susie Green
sgreen@gwaea.org

Student & Parent Information
Student First Name *
Your answer
Student Last Name *
Your answer
Grade *
Your answer
T-shirt Size (based on ADULT SIZES) *
School *
Your answer
School District *
Your answer
Please list any health conditions or allergies (if none, list "none") *
Your answer
Please indicate student's racial or ethnic heritage:
Parent/Guardian Name *
Your answer
Emergency Contact Name/Number *
Your answer
If you are willing to be contacted after the conference regarding your experience, please indicate your preference below *
Student Network Access Form (Required)
To grant your child network (internet) access during the conference, please read our Acceptable Use Policy found at http://bit.ly/gwaeaopenmindsopendoorsconference, and answer the question below.

Please also review the following statements with your daughter and answer the question below indicating that she understands each:
 I have read the expected network etiquette and agree to abide by these provisions. I understand that violation of these provisions may constitute suspension or revocation of Internet privileges.
 I agree to be responsible for payment of costs incurred by accessing any Internet services that have a cost involved.

I acknowledge that I have read the Acceptable Use Policy referenced above and found on the conference webpage. *
I acknowledge that I have reviewed the statements referenced above with my daughter and she understands each. *
Video/Photo Release for Public Information (Optional)
Note: This section is required for children 18 and under whom Grant Wood AEA wishes to photograph or videotape, either individually or in group settings, for publicity or informational purposes of Grant Wood AEA and its programs. A release from the child’s school is not sufficient.

"I (parent/guardian) give permission for Grant Wood Area Education Agency to photograph or videotape my child(ren), myself and/or my family for use by Grant Wood AEA in its publications, websites or promotional literature. I also agree to allow my child’s work to be published by Grant Wood AEA in its publications, websites or promotional literature. I give this consent and will make no further claim of any nature.
I understand that I have the right to revoke this authorization at any time, and that I have the right to request and obtain a copy of the recording or photograph. I acknowledge that I have read the foregoing release and authorization, that I understand its terms, and that I am voluntarily signing this release and authorization."

I agree to the above Video/Photo Release for Public Information for my child. *
If you selected "YES" above, please provide your daughter's birth date:
Your answer
Workshop Selection
The workshop list will be posted online by September 1st at: http://bit.ly/gwaeaopenmindsopendoorsconference
Please list five (5) workshops, in preference order, in which you are interested. Please make sure the workshop number matches the workshop title.
You will be placed in at least one of the following workshops and, if necessary, one alternate determined by the planning committee.
My 1st choice (include the workshop title and number) *
Your answer
My 2nd choice (include the workshop title and number) *
Your answer
My 3rd choice (include the workshop title and number) *
Your answer
My 4th choice (include the workshop title and number) *
Your answer
My 5th choice (include the workshop title and number) *
Your answer
Payment
Send your (non-refundable) $15.00 registration fee to your child’s school ASAP. Checks should be made payable to your school. If you need financial assistance, let your teacher know. Conference scholarships are available.
Additional Information
If you have any additional information or questions regarding your registration, please add those here:
Your answer
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