ACES Registration Form Summer 2014

Activities for Community Education in Science (ACES) Registration Form

Chaperones/Group Leaders should use this form to register their student participants.
Full Name of Registrant (Chaperone)*

PrefixFirst NameLast Name
Relationship to the students*
i.e. parent, teacher, program coordinator, etc.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
This will be the primary mode of contact from the ACES program
Where will the students be coming from?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How will the students be transported to and from the event?*

Student Participant Registration
Number of Students
Student 1 Full Name
Grade (In Sept. 2014)
Student 2 Full Name
Grade (In Sept. 2014)
Student 3 Full Name
Grade (In Sept. 2014)
Student 4 Full Name
Grade (In Sept. 2014)
Student 5 Full Name
Grade (In Sept. 2014)
Student 6 Full Name
Grade (In Sept. 2014)
Student 7 Full Name
Grade (In Sept. 2014)
Student 8 Full Name
Grade (In Sept. 2014)
Student 9 Full Name
Grade (In Sept. 2014)
Student 10 Full Name
Grade (In Sept. 2014)
Student 11 Full Name
Grade (In Sept. 2014)
Student 12 Full Name
Grade (In Sept. 2014)
Student 13 Full Name
Grade (In Sept. 2014)
Student 14 Full Name
Grade (In Sept. 2014)
Student 15 Full Name
Grade (In Sept. 2014)
Student 16 Full Name
Grade (In Sept. 2014)
Student 17 Full Name
Grade (In Sept. 2014)
Student 18 Full Name
Grade (In Sept. 2014)
Student 19 Full Name
Grade (In Sept. 2014)
Student 20 Full Name
Grade (In Sept. 2014)
If any of the listed students have any health or dietary restrictions, please explain. We will be providing some drinks and snacks during the event.
If you would like to register more than twenty student participants, please contact upennwomeninchemistry@gmail.com.

Agreements to Terms
I, the registering chaperone, understand and acknowledge that I am fully aware of and assume the risks (including but not limited to the risk of serious bodily injury, property loss or damage) of the listed minor’s participation in the ACES Program. I understand that the ACES Program and the University of Pennsylvania shall have no responsibility to pay for medical treatment and related costs if said minors are injured during this event (including transportation to and from the event).

I agreeI do not agree
I, the registering chaperone, agree to be responsible for all transportation for the registered student participants.

I agreeI do not agree
On behalf of all the registered student participants listed herein, I, the registering chaperone, consent to the publication and use of the student’s name and/or likeness for the purpose of promotion, publicity, advertising, or other manner or media by the ACES Program. "Likeness" shall include, but not be limited to, photographs, sound and/or video recordings, films, broadcasts, brochures, publications, reports, web pages, promotional materials or any other audio - visual, electronic, printed, tangible work in any media or format, now known or hereafter to become known, and/or repro ductions of any of these. I agree that the actual material involved is and shall continue to be the property of the ACES Program and that neither I, nor the student, shall have any right of review or approval regarding the use of the minor’s name and/or likeness in such material.

I agreeI do not agree
I, the registering chaperone, agree to obtain all necessary parent/guardian permissions in accordance with these terms for the registered student participants.

I agreeI do not agree
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Activities for Community Education in Science (ACES) Registration Form

Student Participant Registration

Agreements to Terms