2021 Discover EGeneral Application Packet

2021 Discover Engineering! Summer Camp: General Application Packet  Discover Engineering! Summer Camp Application Checklist Please complete ALL the following information: (PRINT CLEARLY!) Name of Student: _ DO NOT USE A SCHOOL-BASED EMAIL ADDRESS! Student’s personal email address (not school address): Parent’s email address: Current grade level: _ Student’s Cell Phone: Name of High School: _ General Application Packet: o The Discover Engineering! Summer Camp Waiver of Claim & Permission Slip has been completed:  Yes o Photo/Video/Website Release Form:  Yes o The Chevron Media Release Form has been completed:  Yes o CSU-East Bay Participant Release & Hold Harmless Form:  Yes o Name of Teacher Recommending Student Participation YOU MUST REGISTER ON-LINE HERE: https://www.surveymonkey.com/r/DiscoverE2021 Give your completed packet with parent/guardian signatures to your Nominating Teacher ASAP 2021 Discover Engineering! Summer Camp: General Application Packet Discover Engineering! Summer Camp Student Permission and Hold Harmless Agreement WAIVER OF CLAIM I understand that my child/ward has received approval from me to participate in the Summer Camp This enrichment opportunity is under the direct supervision of at least one teacher and all precautions are taken to ensure each student’s welfare I _, as the parent/guardian of , approve my child’s participation in the Bay Area LEEDS’ Discover Engineering! Summer Camp I understand that the camp will be held virtually in 2021 My child and I are fully responsible for reading, understanding and adhering to the dress code, code of conduct and safety rules required Failure to comply may prevent my child from participation in certain scheduled activities and/or result in removal from the camp I, , hereby irrevocably and unconditionally agrees, to the fullest extent permitted by law, to defend, indemnify, and hold harmless Bay Area LEEDS and its agents, contractors, consultants, volunteers, its officers, directors, employees, successors, and its CSU East Bay Discover Engineering! professors and staff from and against any and all claims, liabilities, losses, suits, proceedings, causes of action, damages, costs, and expenses (including reasonable attorneys’ fees and expenses) (collectively, “Claims”) directly, indirectly, wholly, or partially arising from or in connection with any act or omission of your child and his/her participation in the Discover Engineering! Summer Camp being held virtually from June 21 through June 25, 2021 This includes release, indemnification and hold harmless for (1) bodily injury, illness or death, or for property damage, including loss of use caused in whole or in part by Bay Area LEEDS and its Discover Engineering! Summer Camp agents, contractors, consultants, and volunteers’ negligent acts or omissions This indemnification and agreement shall apply in all instances whether Bay Area LEEDS and its Discover Engineering! Summer Camp agents, contractors, consultants, and volunteers are made a direct party to the initial action or claim or is subsequently made a party to the action by third party in-pleading or is made a party to a collateral action arising in whole or in part from any of the issues emanating from the original cause of action or claim I have read this informed consent, waiver, and release and understand the terms used in it and the legal significance, or, if I did not understand it fully, I have consulted an attorney who has explained it to me This informed consent, waiver, and release is freely and voluntarily given with the understanding that the right to legal recourse against Bay Area LEEDS and its agents is knowingly given up in return for allowing my child's participation in the Program I represent that I am the parent or legal guardian of the student named on this form My signature on this document is intended to bind not only myself but also my successors, heirs, representatives, administrators, and assigns Limitation of Liability IN NO EVENT SHALL Bay Area LEEDS BE LIABLE FOR ANY DAMAGES WHATSOEVER, INCLUDING LOST REVENUE OR ANY CONSEQUENTIAL, INDIRECT, EXEMPLARY, SPECIAL, OR PUNITIVE DAMAGES, REGARDLESS OF THE CAUSE OF ACTION                                                        Signature:  _  Parent/Guardian  Note: Submission of this permission and hold harmless form, along with the required application package, does not connote  acceptance of your child for Discover Engineering! Summer Camp. Your child will be officially notified by the Summer Camp Director  regarding his/her acceptance of the child’s application package.  2021 Discover Engineering! Summer Camp: General Application Packet  Photo/Video/Website Release Form Dear Parent/Guardian: On occasion, representatives from the media or the Discover Engineering! Summer Camp may wish to photograph, videotape, and/or interview students in connection with the Summer Camp Educating the public is one of our objectives The entire community benefits from knowing about the needs and abilities of our students and about the program we offer to children and families In order to release student photos, video footage, comments and/or post on the Discover Engineering! Summer Camp or the Bay Area LEEDS STEM Summer Camp website, we need written permission To give your consent, please complete the form below and mail it with the registration packet I, _ , parent/guardian of give permission for my child to be photographed, videotaped, and/or interviewed by representatives from the media or the Discover Engineering! Summer Camp for the purpose of publicizing the event I authorize the use and reproduction by Bay Area LEEDS, CSU-East Bay or anyone authorized by the Discover Engineering! Summer Camp staff of any and all photographs and/or videotapes taken of my child, without compensation to me/my child All of these photographs/video recordings shall be the property, solely and completely, of Bay Area LEEDS and CSU-East Bay I waive any right to inspect or approve the finished photographs/videotapes, and the sound track, script or printed matter that may be used in conjunction with them Signature of parent/guardian _Date _ Address _ OR I am 18 years of age or older and I give my consent without reservations to the foregoing on my own behalf Signature _Date Address: _   2021 Discover Engineering! Summer Camp: General Application Packet  Release Agreement for Minor Model(s) – for U.S use only I hereby irrevocably consent without royalty or other compensation of any kind, to the use, for any lawful purpose, including but not limited to advertising and trade purposes, by Chevron U.S.A Inc., its subsidiaries, affiliated companies, and successors-in-interest (hereinafter referred to as “Chevron”) of my name, voice and any portraits, likeness, pictures, images, video, film and photographs of me (hereinafter “Images”) taken by or on behalf of Chevron and reproductions of the same in any form, in any medium, including on the World Wide Web, hereby releasing Chevron from all liability arising from use of Images including what I might deem misrepresentation of me by virtue of distortion, optical illusions or faulty mechanical reproductions I agree that all such Images whether plates, transparencies, negatives, film, video, audio, electronic, digital, and/or any medium now or hereafter utilized connected therewith are and shall remain the property of Chevron All copyrights, rights of publicity and other intellectual property rights in Images shall belong to Chevron, and if requested, I will execute any additional agreements to evidence these rights I further agree to the use of statements made by me about Chevron and its various activities for advertising and trade purposes by Chevron I acknowledge that this release constitutes the entire understanding with the above parties, all prior understandings, if any, being merged herein Minor _ Signature Print Minor’s Name Parent or Guardian on Behalf of Minor Print Name Parent or Guardian Witness (can be photographer) Date Photographer Image File Name CALIFORNIA STATE UNIVERSITY E A S T B A Y F O U N D A T ION PARTICIPANT RELEASE AND HOLD-HARMLESS STATEMENT INFORMED CONSENT, WAIVER OF LIABILITY I understand that my child is participating in a California State University, East Bay Foundation (CSUEB) affiliated Program Knowing, understanding, and in full, appreciating all possible risks, I hereby expressly, voluntarily and willingly assume all risks and dangers associated with my child's participation in this Program up to and including death Some common risk situations include travel to and from home and activity meeting location, overnight stay, food poisoning, theft, car accident, tripping, falling, etc I understand this list is not all-inclusive and may not include all eventual situations I declare knowledge and consent for my minor child to travel with the Program for as long as they are a participant in the Program I release and hold harmless the STATE OF CALIFORNIA, the California State University and its Trustees, California State University East Bay, CSU East Bay Foundation, Inc., and each and every officer, employee and agent of each of them, from any and all claims and causes of action that I may have against any of these institutions or persons, by reason of any accident, illness, injury, death, or other consequences resulting directly or indirectly from or in any manner arising out of; or in connection with, my child's participation in the Program I have read this informed consent, waiver, and release and understand the terms used in it and the legal significance, or, if I did not understand it fully, I have consulted an attorney who has explained it to me This informed consent, waiver, and release is freely and voluntarily given with the understanding that the right to legal recourse against the State and its agents is knowingly given up in return for allowing my child's participation in the Program I represent that I am the parent or legal guardian of the student named on this form My signature on this document is intended to bind not only myself but also my successors, heirs, representatives, administrators, and assigns CSUEB Program: Discover Engineering Summer Camp June 21-June 25, 2021 Student Name (please print) _ Parent/Legal Guardian Name (please print) _ Date Parent/Legal Guardian Signature _ Address: _ Emergency contact phone number: ver 01/2021 .. .2021 Discover Engineering! Summer Camp: General Application Packet Discover Engineering! Summer Camp Student Permission and Hold... acceptance of your child for? ?Discover? ?Engineering! Summer Camp. Your child will be officially notified by the Summer Camp Director  regarding his/her acceptance of the child’s? ?application? ?package.  2021? ?Discover? ?Engineering! Summer Camp: General? ?Application? ?Packet? ? Photo/Video/Website Release Form Dear Parent/Guardian:... _Date Address: _   2021? ?Discover? ?Engineering! Summer Camp: General? ?Application? ?Packet? ? Release Agreement for Minor Model(s) – for U.S use only I