InnoWorks 2017 Student Application Information and Instructions

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1 InnoWorks 2017 Student Application Information and Instructions Welcome to the 2017 InnoWorks Workshop Student Application! Since 2003, InnoWorks has successfully conducted 50+ summer workshops, serving over 2,000 InnoWorkers (InnoWorks students), benefiting from the contributions of over 1,000 volunteers. You can find more information at IMPORTANT: Please complete the application if you are interested in being considered for participation in the 2017 InnoWorks Program. Please read the instructions below carefully and follow the directions exactly. Be sure to complete all parts of the application and send in the signed application components in order to be considered. If you have any questions, please contact Application Submission: InnoWorks has very limited resources, so when all conditions are equal, the earlier completed application as determined by the submission time stamp and arrival of signed paper application will be considered first. Please print all information legibly (especially contact information) or we may not be able to process your application in a timely manner. Send the complete, signed paper application via the United States Post Office (USPS) (other carriers may not deliver to PO Boxes) as soon as possible as InnoWorks accepts student on an approved first completed application basis to: Thank you. United InnoWorks Academy PO Box Potomac, MD 20859

2 INNOWORKS 2017 PROGRAM CHAPTERS AND DATES (REQUIRED) Which 2017 InnoWorks Chapter Program are you applying to? (Your selection will herein after referred to as the 2017 InnoWorks Program ) University of California, Los Angeles (UCLA) InnoWorks Program: June 17 23, 2017 University of California, Berkeley (Berkeley) InnoWorks Program: August 14 18, 2017 Duke University (Duke) InnoWorks Program: August 21 25, 2017 University of Maryland, College Park (Maryland) InnoWorks Program: August 14 18, 2017 University of Pennsylvania (UPenn) InnoWorks Program: August 21 25, 2017 Others STUDENT APPLICANT INFORMATION (REQUIRED) (HEREIN AFTER REFERRED TO AS THE STUDENT OR PARTICIPANT ) Student s First Name: Middle Name: Last Name: Is the student eligible for school Free/Reduced Cost Program? Current Grade at school Birth Date: Age: Sex: Yes No 6 th 7 th 8 th High School / / F M Ethnicity: African American Asian Caucasian Hispanic/Latino Multiracial/Multiethnic Native American Pacific Islander Others (please specify) Street Address: Home phone: Cell phone: P.O. box: City: State: ZIP Code: Allergies/Dietary/Health Concerns (please be complete; if none, please enter NONE):

3 RESPONSIBLE PARENT(S)/LEGAL GUARDIAN INFORMATION (REQUIRED) (HEREIN AFTER REFERRED TO AS THE GUARDIAN ) Guardian s First Name(s): Middle Name: Last Name: Relationship to the Student Applicant: Father Mother Step Parent Grand Parent Legal Guardian Other (please specify) Street Address: Home phone: Cell Phone: P.O. box: City: State: ZIP Code: EMERGENCY CONTACT PERSON IF THE PARENT(S) OR LEGAL GUARDIAN(S) ARE NOT REACHABLE (REQUIRED) Adult Contact First Name(s): Middle: Last Relationship to the Student Applicant: Father Mother Step Parent Grand Parent Legal Guardian Friend Other (please specify) Street address: Home phone: Cell Phone: P.O. box: City: State: ZIP Code: BACKUP CONTACT PERSON (REQUIRED) Adult Contact First Name(s): Middle: Last Relationship to the Student Applicant: Father Mother Step Parent Grand Parent Legal Guardian Friend Other (please specify) Home phone: Cell Phone:

4 Name of current school: Address of current school: SCHOOL AND OFFICIAL NOMINATION INFORMATION (REQUIRED) Science teacher or school administrator who can nominate your child for participation in InnoWorks (Student must be nominated by a school official): Position at school: Office phone: Cell phone: REPORT CARDS Please attach a copy of the final or most recent report from the school year. We also require you to submit your child s school year report card, a year following his/her participation in the InnoWorks program. I agree to send my child s final report card for the and School Years to InnoWorks HQ I do not agree to send my child s final report card for the and School Years to InnoWorks TRANSPORTATION TO AND FROM THE 2017 INNOWORKS PROGRAM You will be responsible for dropping and picking your child from the site of 2017 InnoWorks Program Yes We will have transportation for our child No We will not have transportation for our child HAS THE STUDENT APPLICANT PARTICIPATED IN AN INNOWORKS PROGRAM BEFORE? Yes No If Yes, please put a check mark in the appropriate box in the table below Student Junior Mentor Student Junior Mentor Student Junior Mentor Student Junior Mentor Student Junior Mentor Berkeley UCLA Duke Maryland UPenn Johns Hopkins Caltech Other (please specify)

5 JUNIOR MENTOR PROGRAM If your high school student has attended InnoWorks as a middle school student before 2017, would you like the student to be considered for a Junior Mentor position? Yes No INSURANCE INFORMATION (REQUIRED) THE PARENTS/LEGAL GUARDIANS WILL BE RESPONSIBLE FOR ANY MEDICAL COST FOR THE STUDENT PARTICIPANT PARTICIPATING IN 2017 INNOWORKS PROGRAM. Is this Student Applicant covered by insurance during the 2017 InnoWorks Program? Yes No IF YES: Make a copy of the front and back of the insurance card and include it in your application package Person responsible for bill: Birth date: Address (if different from student s): Home phone: / / Cell phone: Occupation: Employer: Employer address: Employer phone no.: Name of primary insurance: ( ) Subscriber s name: Subscriber s S.S. no.: Birth date: Group no.: Policy no.: / / $ Student s relationship to subscriber: Self Spouse Child Other (Please specify)

6 STUDENT INTEREST ESSAYS (TO BE COMPLETED BY THE STUDENT APPLICANT) Please tell us a little bit about yourself, your goals and what you like to do. What do you want to be when you grow up? Why? Why would you like to enroll in the InnoWorks program? What do you hope to gain from participating in InnoWorks? Are you interested in science, technology, engineering, mathematics and medicine? If so, why? If not, why? Have you participated in other science, technology, engineering, and/or mathematics enrichment programs before? If so, please list the program(s) and describe your experience(s). Please include anything else about yourself that you would like us to know about you. (Optional)

7 BEHAVIOR AGREEMENT (TO BE COMPLETED BY THE STUDENT APPLICANT) If I am accepted for participation in 2017 InnoWorks Program, I agree to abide by all United InnoWorks Academy behavior rules and regulations and to follow all directions and guidance from the staff and mentors at 2017 InnoWorks Program. I understand that I will be discharged if I violate my agreement. Participant Signature / Date

8 MEDICAL TREATMENT PAYMENT AUTHORIZATION AND STATEMENT OF FINANCIAL RESPONSIBILITY As parents or guardians for the student applicant, you must agree to be responsible for any cost for medical service provided to your child at 2017 InnoWorks Program if the student is accepted without medical/health insurance. We, the parents or legal guardians of the Student Participant, understand that it is the policy of the United InnoWorks Academy (hereinafter referred to as UIA or InnoWorks) that every participant s parent(s) or legal guardian must accept financial responsibility for any medical treatment to participate in the UIA sponsored activities. UIA requires documentation of private insurance be provided to the UIA in order to be considered for participation in its programs. As we do not have private health insurance for the participant, we are requesting a waiver for such policy in order for our children to be considered for the United InnoWorks Academy summer program at the InnoWorks chapter program of 2017 InnoWorks Program. For such consideration, we hereby voluntarily agree that as a condition for the consideration for acceptance to 2017 InnoWorks Program, we, the undersigned, will be responsible for all costs incurred for any medical attention on behalf of our child during the 2017 UIA Program. Furthermore, as the parents or guardians, I certify that our child, the Student Participant, has our permission to participate in the UIA 2017 InnoWorks Program and agree to the following provisions if accepted: MEDICAL TREATMENT AUTHORIZATION: We recognize that while attending this program, medical treatment on an emergency basis may be necessary for my child, and I further recognize that United InnoWorks Academy (UIA) UIA 2017 InnoWorks Program and/or the University staff may be unable to contact me for my consent for emergency medical care. I do hereby consent in advance to such emergency care, including hospital care, as may be deemed necessary under the circumstances and to assume the expenses of such care. We also authorize the medical facility to release any and all information required including this MEDICAL TREATMENT PAYMENT AUTHORIZATION AND STATEMENT OF FINANCIAL RESPONSIBILITY. By agreeing and/or signing below, we give a medical facility permission to treat my children for injuries or medical problems. In the event of serious injury or illness, the parents or persons designated will be contacted. We will be responsible for payments directly to the medical facility. We do hereby delegate to the 2017 InnoWorks Program of the United InnoWorks Academy, its volunteer staff, mentors, and leadership the authority to seek, obtain, and approve any medical care and treatment including, but not limited to, x ray examination, anesthetic, medical, dental or surgical diagnosis, or treatment and medical care which is deemed advisable by, and is to be rendered under the general supervision of any physician or surgeon, for the above named minors which, in their judgment, is necessary for the health and well being of said minor during their participation in the 2017 InnoWorks Program. We will be responsible for all payments to those medical vendors for all services that these same medical vendors may render. It is understood that this authorization is given in advance of any specific diagnosis or treatment or medical care being required and is to serve as specific consent to any and all such diagnoses, treatment or hospital care which may be deemed advisable. We understand that we are responsible for any costs incurred and we agree to hold the United InnoWorks Academy, its Board of Directors, Staff, Volunteers and agents, the Trustees of the University and the InnoWorks Chapter, its staff, mentors and leadership, or agents harmless for any liability arising out of any good faith actions taken in obtaining medical treatment for the above named minor(s). We understand that the terms and conditions of this agreement shall be legal and binding upon the undersigned parents/ guardian and such child and his/her respective estate, representative and assigns. Parent or Guardian Signature / Date Parent or Guardian Signature / Date

9 PARENT/GUARDIAN PERMISSION AND LIABILITY WAIVER AGREEMENT I/We, the parent(s) or legal guardian(s) of the Student Participant, hereby approve my child s participation in InnoWorks and consent to emergency treatment for my child on my behalf. To the best of my knowledge, there are no physical or other conditions that will interfere with my child s participation. I understand that due to the physical nature of some of the team activities, there is a certain amount of inherent risk associated with participation. By my signature below, I do hereby waive and release any and all claims in any right for claims for damages we/i have against InnoWorks, the university at which the program is being hosted, students, and staff members for any and all injuries suffered by us at InnoWorks. InnoWorks, its staff, students, and workers assume no liability for injury or damages arising from the 2017 InnoWorks Program. I/we have also read, agreed and signed the Participation Agreement and Waiver below. If we do not have personal health insurance, I/we have read, agreed and signed the Medical Treatment Payment Authorization and Statement of Financial Responsibility and we accept all financial responsibility for any medical treatment required for my child during the 2017 InnoWorks Program if my child is accepted to participate in 2017 InnoWorks Program. Parent or Guardian Signature / Date Parent or Guardian Signature / Date

10 PARTICIPATION AGREEMENT AND WAIVER PARENTAL CONSENT AND RELEASE OF LIABILITY AGREEMENT THIS IS A LEGAL CONTRACT AND AFFECTS ANY RIGHTS YOU MAY HAVE IF YOU ARE INJURED OR OTHERWISE SUFFER DAMAGES WHILE PARTICIPATING IN 2017 INNOWORKS PROGRAM. This Participation Agreement must be read carefully, agreed to and signed by all participants, their parents and/or legal guardians. If a provision of this Agreement is or becomes illegal, invalid or unenforceable in any jurisdiction, that shall not affect: 1) the validity or enforceability in that jurisdiction of any other provision of this Agreement; or 2) the validity or enforceability in other jurisdictions of that or any other provision of this Agreement. In consideration of United InnoWorks Academy and 2017 InnoWorks Program, I/we, being the parent(s) or legal guardian(s) of the Student Participant, understand and agree to the following if the participant is accepted to 2017 InnoWorks Program: 1. Inherent Risks and Dangers of Participation and Travel: I/we understand and appreciate that there are risks and dangers inherent when traveling and participating in group activities such as 2017 InnoWorks Program. For 2017 InnoWorks Program, my child may travel by vehicles provided by InnoWorks, its staff, volunteers, and members of InnoWorks, faculty or employees of the University during 2017 InnoWorks Program. I/we and our child understand that not following procedures properly could result in property damage and personal injury, including death. I/we voluntarily elect to allow my child to participate in 2017 InnoWorks Program at my/our own free will, and agree to accept and assume all risks associated with the activity whether present or future, known or unknown, arising from or as a result of my child s voluntary participation in the activity. Understanding all of the risks involved, I/we hereby voluntarily allow my/our child to participate in 2017 InnoWorks Program. 2. Participation in research: I/we know that the InnoWorks program will be collecting data through observations, direct dialog with my/our child, surveys, photographs, recording and videotaping during the workshop for research, reporting, publishing, and marketing, with the goal of improving InnoWorks and providing metrics to the sponsors. I/we will provide a copy of my/our child s most recent report card that I/we received before 2017 InnoWorks Program and those I/we receive within the next school year after 2017 InnoWorks Program. I/we also grant InnoWorks access to my child s grades in the specified time frame through school officials. I/we understand that United InnoWorks Academy will do its utmost to maintain data integrity and protect its confidentiality. No individual statistics will be reported, only group/aggregated statistics with no individual identification will ever be reported. With full understanding of this requirement, I/we elect to voluntarily allow my child to participate in 2017 InnoWorks Program and give my/our permission for InnoWorks and its staff to use the data collected for its research, reporting and marketing, etc.. 3. Behavior Expectations of the Participant: I/we know that it is important to follow the directions of the InnoWorks staff and mentors at all times. I/we have made my child understand that as a participant, they have the responsibility to help make the activity a safe experience for all participants through appropriate behavior and conduct. I/we have also made my child understand the dangers that may be caused by not following directions and they have agreed to follow directions at all times while at 2017 InnoWorks Program. 4. Health Condition and Medical Treatment of the Participants: I/we agree to: a. Provide health information to and inform the Director and staff of 2017 InnoWorks Program of any medication, ailment, condition, or injury that may affect my child s performance in the activities of 2017 InnoWorks Program. b. Give medical facilities prior permission to treat my children for injuries or medical problems they deem necessary and accept all financial responsibility for all associated costs c. that InnoWorks may make cancellations, changes or substitutions in cases of emergency or changed conditions or in the interests of the group or program. d. that I/we and my/our child understand that as participants in this InnoWorks program at the

11 University, we are representatives of InnoWorks and the University. By signing this agreement, we pledge to conduct ourselves in a manner that reflects favorably on all. e. that I/we understand that InnoWorks and the University requires all participants to be covered by appropriate health and accident insurance and those participants and their families must be financially responsible for all medical expenses and for expenses related to evacuation and repatriation unless otherwise provided. In addition, I/we agree that payment for medical expenses customarily is advanced and reimbursement sought later from the insurance carrier. InnoWorks and the University require that any participant planning to operate a motor vehicle obtain liability and collision insurance that will cover him or her in the participation of InnoWorks InnoWorks and the University also recommend that participants insure their property against loss or theft. 5. Release, Assumption of Risk, Waiver of Liability and Hold Harmless Agreement: I/we agree for my/our child to participate in 2017 InnoWorks Program and having read and understood this Participation Agreement, I/we hereby state that I voluntarily agree to the following: a. By virtue of signing this document, I/we, my children, my family, my spouse, my heirs, assigns and persons who may represent me RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE the United InnoWorks Academy, its officers, volunteers, staff, mentors, workers or officers, members of the University Chapter of InnoWorks, the University, its trustees, officers, employees or agents, (who will be referred to as RELEASEES in the rest of this document) for any liability, claim, and/or cause of action that might be arising out of or related to any loss, damage, or injury, including death, that may be sustained by me, my child/children or to any property belonging to me that occurs as a result of my participation in as well as traveling to and from activities associated with InnoWorks and 2017 InnoWorks Program. b. I/we agree to INDEMNIFY, to make compensation to for damage, loss, or injury suffered AND HOLD HARMLESS the RELEASEES from any loss: I/we agree to not hold the RELEASEES responsible for any injury, loss or damages which my child/children or I/we may suffer at InnoWorks, whether injury or damages is caused by my negligence, the negligence of the RELEASEES or the negligence of any third party. c. I/we hereby further agree that this Participation Agreement, Release, Assumption of Risk, Waiver of Liability and Hold Harmless Agreement shall be construed and interpreted in accordance with the laws of the state in which the InnoWorks Chapter operates. d. If I/we depart or deviate from any aspect of this activity, such deviation is purely voluntary, and e. I/we agree that RELEASEES shall not be liable for any injuries resulting or arising out of such deviation. e. I/we understand that by participating in InnoWorks 2017, I/we will ASSUME THE RISK of injury and damage from risks and dangers that are inherent in any activity. If a provision of this Agreement is or becomes illegal, invalid or unenforceable in any jurisdiction, that shall not affect: 1. the validity or enforceability in that jurisdiction of any other provision of this Agreement; or 2. the validity or enforceability in other jurisdictions of that or any other provision of this Agreement. IN SIGNING THIS RELEASE, I/WE ACKNOWLEDGE AND REPRESENT that I/we have read this PARTICIPATION AGREEMENT, understand, agree and sign it voluntarily. Parent or Guardian Signature / Date Parent or Guardian Signature / Date

12 Final Check List for Completing the Application Consideration for acceptance will be with the order of completed application received. Incomplete applications will not be considered. Please sign all the printed forms and mail via the United States Post Office (USPS) (other carriers may not deliver to PO Boxes) as soon as possible as InnoWorks accepts student on an approved first completed application basis to: United InnoWorks Academy PO Box Potomac, MD Please make sure to include in the mailed package. Applications without all original signatures (from parent/guardian and participant where applicable) will not be accepted: Original, signed application including all pages, Copies of the front and back of your insurance card, Report card(s) Thank you.

INSURANCE INFORMATION

INSURANCE INFORMATION These forms must be completed and signed in all appropriate places by the participant, the participant s physician, and if under age 18, by the participant s legal guardian. The medical information we