Mentor/Volunteer Registration Form

Mentor/Volunteer Registration Form
Consent, Release, Hold Harmless, and
Authorization to Reproduce Physical Likeness
Complete information below (please print legibly).
Date:
MENTOR/VOLUNTEER INFORMATION
BADGERBOTS
PROGRAM:
Minor League
FTC
FLL
FRC
SUMMER DAY CAMP
MENTOR/VOLUNTEER NAME:
DOB:
COMPANY OR SCHOOL ATTENDING:
COMPANY OR SCHOOL ADDRESS:
HOME PHONE:
(
)
WORK PHONE (OPTIONAL)
(
)
CELL PHONE:
(
)
GENDER:
Male
Female
OTHER PHONE:
(
)
PRIMARY EMAIL ADDRESS:
SECONDARY EMAIL ADDRESS (OPTIONAL):
ADDRESS:
CITY:
PERSON TO CONTACT IN CASE OF EMERGENCY:
RELATIONSHIP:
STATE:
ZIPCODE:
CELL PHONE:
(
)
HOME PHONE:
(
)
ADDITIONAL EMERGENCY CONTACT INFORMATION (Optional)
EMERGENCY CONTACT #1:
RELATIONSHIP:
CELL/HOME PHONE: (
)
WORK PHONE: (
EMERGENCY CONTACT #2:
RELATIONSHIP:
CELL/HOME PHONE: (
WORK PHONE: (
)
)
)
MEDICATION / MEDICAL CONDITION
Please describe medications and medical conditions ONLY if they affect your safety or the appropriate medical treatment should an
injury or illness occur.
MEDICINE:
WHEN IS IT ADMINISTERED:
DOSAGE:
MEDICINE:
WHEN IS IT ADMINISTERED:
DOSAGE:
MEDICATION CONDITION :
SYMPTOMS:
APPROPRIATE RESPONSE:
ALLERGIES (FOOD OR OTHER):
Your signature grants BadgerBOTS Robotics Corporation and its agents the right to authorize emergency medical treatment to you if you are unable to
provide consent yourself at the time.
____Initials
T-SHIRT SIZE (CHOOSE ONE BELOW)
Youth S
Youth M
Youth L
Adult S
Adult M
Adult L
Adult XL
Adult XXL
Adult XXXL
BadgerBOTS Robotics
Mentor / Volunteer Registration Form
(page 2)
WAIVER AND RELEASE; PLEASE READ AND SIGN BELOW
___________________________________________________________(please neatly print mentor/volunteer name), agrees to the following conditions to
participate in all activities related to BadgerBOTS Minor League, FLL, FTC, FRC and Summer Camp programs.
As used below, “BadgerBOTS” shall mean the non-profit corporation known as BadgerBOTS Robotics Corporation and its directors, officers, advisors,
leaders, mentors, teachers, volunteers, agents and assigns. As used below, “Participant” shall mean any individual involved in BadgerBOTS in any way,
shape or form.
I agree to the following:
Use of Likeness. BadgerBOTS, or anyone authorized by BadgerBOTS, has the right to make and have made, publish, reproduce, use, translate, and
reuse any photograph(s), videotape(s), voice recording(s) or likeness(es), including, use of said content in any advertising, promotional or publicity matter or
purposes. I further agree that BadgerBOTS may use said content in any format now known or later developed, including but not limited to electronic
publication. All photographs, negatives, prints, transparencies, drawings, reproductions, videotape, voice recordings, electronic files, sketches and written
works made by or for BadgerBOTS shall be the exclusive property of BadgerBOTS.
Authorization for Emergency Medical Treatment. In the event I sustain injuries or illness while involved in BadgerBOTS, I hereby authorize
BadgerBOTS to administer, or cause to be administered, such first aid or other treatment and medications I may bring as may be necessary under the
circumstances, to include treatment by a physician or hospital of BadgerBOTS’ choice.
Release from Liability. The undersigned, being fully cognizant of the risks in participation in a science, technology, engineering, mathematics and robotics
focused program, hereby assumes the risks of bodily injury (including, without limitation, death) and property damage, inherent in such participation. I
hereby release BadgerBOTS and their respective successors, affiliates, licensees and assigns from all claims, demands, liabilities, damages, costs and
expenses (including, without limitation, attorneys’ and other professional fees and expenses) that I may now or hereafter have against BadgerBOTS arising
in connection with my participation in BadgerBOTS programs and their exercise of rights hereby granted, including, without limitation, claims for
compensation, defamation, or invasion of privacy, or other infringements or violations of personal or property rights of any sort whatsoever. This waiver
and release shall also inure to the benefit of the successors, assigns, and licensees of BadgerBOTS.
This Release shall be binding upon my heirs, personal representatives and assigns, and me and shall be governed by and construed under the laws of the
State of Wisconsin without regard to conflicts of laws principles. Venue for any legal action arising out of or in connection with this Release shall be in Dane
County, Wisconsin, and jurisdiction shall be vested exclusively in the District Court in and for Dane County, Wisconsin, or, if appropriate, in the Federal
District Court for the District of Wisconsin. This Release constitutes the entire agreement among the parties hereto with respect to the subject matter of this
Release and supersedes any and all previous agreements among the parties, whether written or oral, with respect to subject matter.
I understand there is no registration fee to be a mentor/volunteer; however, there may/will be costs for team competitions, field trips or
other special events.
I understand that a background check will be completed on me and that BadgerBOTS reserves the right to refuse participation of an
individual based on the outcome.
In the event I am injured or become ill while involved in a BadgerBOTS activity, I hereby authorize such aid or treatment as may be
necessary under the circumstances to include treatment by a physician or hospital.
I give BadgerBOTS my permission to mail or email me about program information or additional information about current and future
BadgerBOTS events and activities. We understand that having your personal information is a privilege and would never give or sell your
information to another organization. At any time you want to discontinue receiving emails from BadgerBOTS, simply contact us or opt-out
in the footer of the email.
SIGNATURE OF MENTOR/VOLUNTEER
DATE:
For additional information contact BadgerBOTS Robotics Corporation, 7615 Discovery Drive, Middleton, WI 53562;
[email protected] ; (608) 831-6480; www.badgerbots.org
FOR OFFICE USE ONLY:
BACKGROUND CHECK COMPLETED:
Revised 9/1/2012
DATE APPROVED: