MTSU Expanding Your HorizonsMiddle Tennessee State UniversityParent/Guardian Release FormSeptember 26, 2015
All fields are required. If not applicable indicate with “NA”.
Does your child have special needs that necessitate accommodations or assistance for any of the following
Other medical/health concerns (if there are none indicate with "N/A"):
If a special needs situation arises after you register, please contact 615-494-7763.
MTSU EYH LIABILITY RELEASE, WAIVER, DISCHARGE AND COVENANT NOT TO SUE This activity presents the risk of injury. This exculpatory release confirms that the participant who signs below accepts all aspects of that risk.
I have read the above liability release statement and fully understand and accept all aspects of that risk.Yes
Photo Permission: I give my consent for MTSU 2015 EYH Conference to use photos, videos, and/or audio tape that include my daughter for the purpose of publicizing and promoting Expanding Your Horizons. I understand that the images or voice recordings may be published in newspapers or magazines, on the World Wide Web, or be broadcast on television or radio. Names and other private information such as addresses, phone numbers, email or schools will NOT be published. If permission for pictures is not granted, your child will be assigned to a group where no pictures will be allowed and thus will not have a choice of workshops.
I have read the above photo permission statement and accept or decline.
Pre and Post Survey Permission: I give my consent for my child, who is participating in the Expanding Your Horizons in Science and Mathematics Conference (EYH) to participate in a survey which will help us gauge the effectiveness of the MTSU EYH program. This is an optional and anonymous survey. If your child decides to participate, she will be asked to complete a pre-survey, post-survey, and a group evaluation detailing their experience at the conference. Your child's participation will help us to further understand the success of the EYH conference pertaining to their interests in science and math. We will collect no information with this study that will identify your child. Results will also be averaged so that specific results of a particular survey question cannot be traced back to any specific participant. Your child's participation is voluntary. Her decision whether to participate or not will not affect her EYH experience. If your child chooses to participate, she is free to decide not to complete the survey at any time without consequence or penalty.
I have read the above post survey permission statement and accept or decline
If you have questions about this release form please contact us at 615-494-7763.After submitting, you will be directed to the National EYH site to indicate workshop preferences.
2015 Middle Tennessee State University, a Tennessee Board of Regents institution 1301 East Main Street, Murfreesboro, TN 37132-0001 USA +1-615-898-2300 Middle Tennessee State University, in its educational programs and activities involving students and employees, does not discriminate on the basis of race, color, religion, creed, ethnic or national origin, sex, sexual orientation, gender identity/expression, disability, age (as applicable), status as a covered veteran or genetic information.