Registration for Copper Country Math Circle at the Keweenaw Bay Ojibwa Community College

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Please complete the following information to register for the Copper Country Math Circle at Keweenaw Bay Ojibwa Baraga College Campus on Wednesday, March 13, 2019 3:00 - 4:30pm with possible April & May follow-up dates TBA
Please sign up each child individually.
For more information visit located http://www.coppercountrymathcircle.com

Student First Name *

Student Last Name *

Student Grade Level *

School District *

Parent/Guardian Name *

Parent/Guardian Email *

Parent/Guardian Phone Number *

Address *

Person(s) authorized to pick up your child/Emergency contact *

Please list all people who may potentially pick up your child along with their phone number and relationship to the student.

Please list any medical conditions along with medications associated with your child (bee/peanut/shellfish allergies, asthma, diabetes, etc.). *

If your child has an inhaler, epi-pen, or insulin injections, please specify.

Does the Copper Country Math Student Circles have permission to use photos of your child in educational or promotional materials? *

Yes

How did you hear about our program?

Please read the following liability release and parental consent and type your name in the box provided below. *

I, the undersigned participant, or parent/guardian of a minor participant in the Copper Country Math Circle, understand that there are inherent risks that cannot be eliminated in this activity and that each participant must assume the risk of injury or disabilities that could result from any of the activities. I hereby acknowledge that I am aware of these risks and I agree that I will, or if signing as a parent or guardian I will advise the participant to follow all safety instructions and ask questions if I or they do not understand. In consideration of the acceptance of myself or the minor as a participant in Copper Country Math Circle, I assume the risk of and full responsibility for any bodily injuries, death, damages or expenses to me, or the minor for whom I am signing which may occur in the course of or as a result of my or their participation in this activity. I do hereby fully and forever release and discharge, covenant not to sue and agree to indemnify and hold harmless Keweenaw Bay Ojibwa Community College, its Board, employees, and agents from and against any and all claims, demands, damages or rights of action due to bodily injury, death, or property damage, present or future, whether the same be known or unknown, anticipated or unanticipated, resulting from or arising out of my participation, or the minor’s participation in the Copper Country Math Circle or its activities.In addition, I understand Keweenaw Bay Ojibwa Community College may need to respond to accidents and potential emergency situations. Therefore, I hereby give my consent for any emergency medical treatment that may be required during my participation, or the minor’s participation in the Copper Country Math Circle with the understanding that the cost of any such treatment will be my responsibility.Michigan Technological University reserves the right to use any pictures taken during the Copper Country Math Circle program for advertising and/or instructional purposes.I have read the foregoing, explained its meaning to my child or ward if the participant is a minor, and hereby do approve and consent to the terms and conditions stated. If the participant is a minor I consent to the participation of my son or daughter in the Copper Country Math Circle.

Thank you! Visit For more information visit located http://www.coppercountrymathcircle.com for more information

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