Electronic Signature Form

Electronic Signature Form
JA Business Week 2016 ▪ June 5-10, 2016
Johnson & Wales University ▪ Denver, Colorado
This form must be submitted for your registration to be considered complete. When the registration
form is complete, the $25 registration fee received, and this electronic signature form submitted you
will receive an email indicating that your registration is complete.
Thank you for submitting your registration for JA Business Week 2016! To complete the registration process, you and
your parent/guardian must confirm that you completed your registration form together by submitting this signature form.
A copy of the registration form is available for you to reference and download at www.JABusinessWeek.org.
FIRST: Parent/Guardian and Student review the summary of information from the JA Business Week registration below.
THEN: Parent/Guardian and Student sign the signature page.
LASTLY: Once you have filled out the form, select Submit Form in the upper right corner of the document. Please
use Adobe whenever possible, especially if you are using a MAC. You can download Adobe Reader here for free.
If the Submit Form button does not appear in the upper right corner of the document, please email the completed
form as an attachment, or send via mail or fax.
Contact info:
Junior Achievement
Attn: JA Business Week
1445 Market St., Suite 200
Denver, CO 80202
Phone: 303-260-6285
Fax: 303-534-2771
Email: Jill Hrnicek | [email protected]
REMINDERS
Eligibility: Current high school students in Colorado or Wyoming; must have completed ninth grade, may be
recent graduates (class of 2016).
Cost: $550, includes $25 registration fee. Click here to learn how the JA Business Week Tuition Rewards
Program can help cover the cost of the JA Business Week fee.
Step 1: Register - Complete the Student Registration Form.
Step 2: Square Up! Pay the $25 registration fee* now. The remaining balance will be due by
Friday, May 06, 2016.
*All students, even those applying for scholarship, must submit this non-refundable registration fee
at the time of registration.
Step 3: Optional - Complete the Scholarship Application. If you are not completing the
Scholarship Application, you need only complete Steps 1 & 2.
Acceptance: Once all registration material (Registration Form, $25 Registration Fee, and this Signature
Form) is received, then the student will be accepted to the program.
Communication: You will receive any additional information via e-mail, so please check your email
regularly. Please contact Jill Hrnicek at [email protected] with any questions you have.
Health Information
The online application for JA Business Week requests health information from student applicants. Your signature confirms that you and
your student provided accurate, up to date information in the online application about the following:
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Food, drug, plant, insect or other allergies and/or dietary restrictions
Current or past behavioral diagnosis
Current medications and instructions for student’s use. Students are responsible for administering their medications
Any critical information regarding the applicant. This may include accessibility needs, etc.
History with asthma, shingles, heart problems, chicken pox, hepatitis, mononucleosis, diabetes, herpes, seizures, and/or other
diseases
The online application required the following commitment regarding your student’s health:
I understand that Junior Achievement-Rocky Mountain Inc. is not liable for any physical injuries that may occur during this program. All
steps have been made to ensure a safe and healthy learning environment. There will be several adult staff members supervising the
students at all times. Junior Achievement-Rocky Mountain Inc. will immediately inform parents/guardians of any accident that may
occur.
I am stating that this health history is correct so far as I know, and the person herein described has permission to engage in all
prescribed program activities except as noted. I hereby give permission to the medical personnel selected by the JA Business Week
Manager to supply all necessary medical treatment to the above student. I further agree to assume responsibility for the cost of any
means of transportation related to medical care and any medical care costs are the financial responsibility of the undersigned. This
completed form may be photocopied for trips off campus.
Transportation Information and Waiver
The online application required the following regarding transportation at JA Business Week:
TRANSPORTATION WAIVER for Junior Achievement-Rocky Mountain Inc., JA Business Week, June 5-10, 2016 at Johnson &
Wales University, Denver, CO
I understand that Junior Achievement-Rocky Mountain Inc. is not responsible for any transportation-related injuries that may occur
during this event. The only transportation that will be utilized during this week is an insured bus line. All buses have full insurance and
your child will be covered under their policy. If your student decides to use any unauthorized form of transportation, Junior
Achievement-Rocky Mountain Inc. is not liable. Please note that all measures will be taken to prevent the above situation. If a student
brings their own car, the keys will be held by JA Business Week staff until the end of the program. If a student uses unauthorized
transportation, s/he will be immediately expelled from the program.
Code of Ethics
The online application required a review of the Code of Ethics for JA Business Week, which are below. To ensure the safety and wellbeing of all students, staff, and volunteers at JA Business Week, it is important that everyone understands and follows the same
standards. Please take the time to read and sign the Code of Ethics. Serious offenses will result in immediate expulsion from the
program as noted. “Strikes” are given for lesser offenses listed below. If a student receives three strikes throughout the week, the
student will be immediately expelled. No refund is awarded for expulsion.
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The possession or use of alcohol, tobacco, illegal drugs or weapons are not permitted and will result in immediate expulsion.
Students are required to stay on campus the entire week: Sunday, June 5 at noon until Friday, June 10 at 4:00 pm. Leaving
campus without approval will result in immediate expulsion. The two exceptions to this regulation are as follows: (1) extreme
family/health emergencies and (2) planned JA Business Week field trips. The week’s schedule will be given to students on June
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5 at check-in.
Sexual conduct will result in immediate expulsion.
Female students are not allowed on male dorm floors, and male students are not allowed on female dorm floors. Violations will
result in immediate expulsion.
Students are not allowed to have visitors during the program. If a visitor comes to campus, the student receives one strike.
The first floor lobby of each dorm building will be open until 10:00pm for supervised co-ed use. Students must be inside their
dorm building by 10:00pm. Each violation results in one strike.
Curfew, the time students must be inside their assigned dorm room, is 10:30pm. Quiet hours begin at 11:00pm. These times will
be enforced by the staff; each violation results in one strike.
Students must be present at and on-time to all meetings, speakers and other activities and functions. Tardiness to any activity
results in one strike.
Students must act professionally and appropriately during all speakers’ presentations, workshops, company meetings and
activities. This includes, but not limited to: not sleeping/putting head down, listening to iPods, texting, etc. At the discretion of the
JA Business Week staff, students will receive one strike for inappropriate behavior.
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Appropriate clothing must be worn at all times during the program (details will be provided in the Acceptance Packet, which is
emailed upon acceptance to the program). Shoes and shirts are required at all times. Clothing with inappropriate or explicit
language or graphics is not allowed. A violation results in one strike.
JA Business Week maintains an environment where harassment or discrimination of any kind is unacceptable and can result in
immediate expulsion or one strike, depending on the severity of the violation. No staff member, volunteer or program
participant shall harass or discriminate against another staff member, volunteer or program participant on the basis of race, color,
creed, religion, gender, age, national origin, citizenship, veteran or marital status, sexual orientation or the presence of any
sensory, physical, mental handicaps or other legally protected status.
Anyone in the willful companionship of another person violating the JA Business Week Code of Ethics will receive immediate
expulsion or one strike, depending on the severity of the violation.
Johnson & Wales dormitory use:
o Rooms and roommates are pre-assigned. Students are not allowed to move to a different room. Each participant will be
provided with a room key and s/he is responsible for it. If students lose their key, students will be responsible for paying
the $65 Lost Key charge.
o If there is any damage to the room upon check-out, the student who caused the damage will be responsible for the cost of
repair. If neither student claims responsibility, both students will split the charge.
o Students are not to be in any personal vehicle during the program. If he/she brought a vehicle to campus, all needed items
should be removed upon arrival, so that the vehicle does not need to be accessed during the week. Junior Achievement
staff will collect keys during check-in and will retain the keys until the end of the week.
o For students’ own safety and the safety of their personal belongings, their dorm must be locked when not in their room.
Neither Junior Achievement nor Johnson & Wales University are responsible for student belongings.
In summary:
Violations that Result in Immediate Expulsion*
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Possession or use of alcohol, tobacco, illegal drugs or weapons
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Leaving campus without approval
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Sexual conduct
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Female student in male dorm building; male student in female dorm building
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Harassment or discrimination (based on severity)
Violations that Result in One Strike (3 Strikes = Immediate Expulsion)**
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Not present or on time to a scheduled meeting, workshop, etc.
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Inappropriate behavior (including using cell phones) during meetings, workshops, etc.
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Inappropriate clothing
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Harassment or discrimination (based on severity)
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Visitor on campus
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Breaking the following curfews:
o 10:00pm – in dorm building
o 10:30pm – in assigned dorm room
o 11:00pm – quiet hours begin
*Parents/guardians are notified as soon as possible and must pick up their child from JA Business Week immediately, regardless of the
time of day/night.
**Students report to Headquarters as soon as possible (this is the JA Business Week office on campus, open 8am-8pm) to call their
parents/guardians and to sign their Incident Report form.
Media Release
The online application required the following regarding media for students who participate in JA Business Week. You agreed to the
following: In consideration of the opportunity to be pictured as described below, I, the parent or legal guardian, hereby grant Junior
Achievement’s photographer(s) and videographer(s) and their designees the right to photograph and/or video tape (hereafter called
"media") my child. My child is a participant of JA Business Week 2016, and I hereby grant Junior Achievement the irrevocable right and
permission to:
1) Reproduce, use, re-use, publish, display, copyright and distribute all media taken in which my student might appear and in
connection with any and all media now known or hereinafter developed, for all purposes and in perpetuity.
2) Reproduce, use, re-use, publish, display, copyright, and distribute the same, individually or in conjunction with other photographs,
images, text, and/or captions in connection with any promotion, advertising, and publicity of Junior Achievement in all media for all
purposes and in perpetuity.
I also release and discharge Junior Achievement from any and all claims, demands and liability in connection with the use of such
media in connection with Junior Achievement, including but not limited to claims for libel, invasion of privacy, rights of publicity and/or
copyright infringement. I understand that the copyright to all media resides with Junior Achievement. If you do not want your JA
Business Week students to be featured in media, please contact Kim McGrigg, director of communications for Junior Achievement at
303-260-6295 or [email protected]
For JA Office Use Only:
Final Signature
Accepted
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Scholarship
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In order to complete your application, select Submit Form in the upper right corner
of the document. Please use Adobe whenever possible, especially if you are using a MAC. You can download
Adobe Reader here for free.
If the Submit Form button does not appear in the upper right corner of the document, please email the completed
form as an attachment, or send via mail or fax.
CONTACT INFO:
Junior Achievement
Attn: JA Business Week
1445 Market St., Suite 200
Denver, CO 80202
Phone: 303-260-6285
Fax: 303-534-2771
Email: Jill Hrnicek at [email protected]
Final Signature from Student and Parent/Guardian
By signing this agreement, I hereby certify that:
I have read, understand, and will comply with the summary of standards above.
I understand that my registration will be reviewed upon receipt. All information contained in the registration is correct to the best of my knowledge. I
have completed registration by submitting the $25 registration fee. I understand that upon acceptance to attend JA Business Week 2016, I will submit
the remaining fee of $525 (unless the scholarship is awarded or student participates in Tuition Rewards) by Friday, May 06, 2016.
I have read, understood, and provided all necessary information in the following sections in the JA Business Week application. Please check
each box to confirm below:
 Health
 Transportation
 Code of Ethics
 Media Release
Student Signature:
Date:
Print Student Name:
Parent/Guardian Signature:
Print Parent/Guardian Name:
Date: