Speak Up Registration Form Spring 2020

Speak Up! Teen Creative Writing and Performance Program

Spring 2020

Miami Dade College is providing a weekly after-school creative writing program for students participating in the Speak Up: Creative Writing + Performance Program on Mondays, February 3 – April 27 (11 weeks) from 4:00 – 7:00 p.m. at the Koubek Center. Participating Students will be selected by Miami Book Fair staff and will be chaperoned by College’s Miami Book Fair/Speak Up staff members at all time. In order to participate in this program, parents/guardians on behalf of, and together with the Participating Student, must read, understand and agree to the terms and conditions set forth herein.

Student Legal Name*

First Name

Last Name

Preferred Name/Nickname/Pen Name

Student Phone*

Student Email*

Preferred mode of contact (i.e. email, message, whatsapp, etc)*

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

How old are you?*

What grade are you in?*

Which school do you attend? (If homeschooled, please specify whether you are part of a specific program)*

Gender (please list pronouns) [Please note: this question is optional and does not effect your application status.]

Ethnicity (please list all that apply) [Please note: this question is optional and does not effect your application status.]

Primary Language Spoken at Home?*

What mode of transportation would you be using to and from workshop? (please list all that apply)*

What social media platform(s) do you prefer, if any? List all that apply. Feel free to include your social media handle(s)!

Is there anything specific you would need from the facilitators or the workshop/open mic space in order to fully participate?

Parent/Legal Guardian Name*

First Name

Last Name

Parent/Legal Guardian Phone*

Parent/Legal Guardian Email*

Is this person your Emergency Contact?*

Yes No

If your parent/legal guardian is not your emergency contact, please provide the name, email, and phone number of your Emergency Contact:*

Secondary Emergency Contact (name, relation, number)

I am the Parent and/or Guardian for the Participating Student identified above and together with my Participating Student hereby make the following legally binding representations and acknowledgements and provide my consent to The District Board of Trustees of Miami Dade College, Florida (“College”) on behalf of Participating Student and on behalf of me, all next of kin, heirs, legal representatives, successors and assigns:

Agree that as part of Participating Student’s participation in this Speak Up Program I understand that all individuals must be treated with respect, including other students, College and M-DCPS personnel, and all other persons participating in the Speak Up Program.

I agree to not engage in any inappropriate behavior, including but not limited to, physical altercations.
I agree to wear appropriate attire at all times and agree not to wear any clothing which contain nudity, obscene or derogatory images or words.
I understand that I must stay with the College group unless permission is given by one of the College or M-DCPS Personnel. In the event this permission is given, I agree to return to the designated location by the designated time.
I understand that I am responsible for any expenses beyond what is provided by Speak Up.
I understand that I am solely responsible for any property that I bring and I am solely responsible for any damage that may occur to any of my personal property.
I agree that I am not permitted to bring any weapons, including but not limited to, guns and knives regardless of whether or not I have a concealed weapons permit.
I understand that the possession and/or use of any alcohol, tobacco products, e-cigarettes, and illegal substances is absolutely prohibited.
I understand that by going to and participating in the Speak Up Program, the College may record my likeness, voice, art work, possessions and other content in any medium, including, but not limited to: print, video, audio, photograph, digital, electronic or any other method of publication/communication (collectively referred to as “Recordings”).
I authorize the College to use, reproduce, exhibit, distribute, advertise, broadcast, edit, promote, record, webcast, podcast, market or otherwise commercially utilize any or all of these Recordings, in whole or in part, in perpetuity by any and all means, media, devices, processes and technology whether now known or hereafter developed throughout the whole universe, including, but not limited to, television, radio, online/internet, mobile, wireless, theatrical and home distribution, sound recording, publishing, commercial, and merchandising.
I understand that these Recordings may be used for commercial purposes, but solely for the use of the College. The College may edit, use/not use and republish/rebroadcast such Recordings for any purposes including, but not limited to, use as classroom instruction; closed-circuit television or digital transmission on campus, MDCTV, or to off campus class meetings, assemblies or events; independent instruction; recruitment; marketing and promotion; news and, any other purposes of the College. I understand that I am not entitled to a copy of these Recordings.
I explicitly waive any rights I may have under the Family Educational Rights and Privacy Act (“FERPA”) and/or § 1002.225, Fla. Stat., or any other right to privacy as it relates to these Recordings and my activities herein.
I forever release and agree to indemnify The District Board of Trustees of Miami Dade College, Florida, its board members, officers, employees, volunteers and anyone associated or affiliated with these entities or persons from any and all liability, loss damage, expense, or cost of any kind of nature whatsoever from any and all claims for property damage, personal injury, including death, and/or any other claims arising from my participation in the program, including claims that are known or unknown, foreseen or unforeseen, future or contingent.
I agree that I shall not now nor at any time in the future, directly or indirectly, commence or prosecute any action, suit or other proceeding against the College, its board members, officers, employees, volunteers and anyone associated or affiliated with these entities or persons arising out of, relating to, or in connection with the actions, causes of action, claims and demands hereby waived, released or discharged by me.

In the event that I am unable to otherwise affirmatively make my intentions known, I consent to receive basic life sustaining medical treatment in the event of injury, accident, and/or illness during my participation on this trip and during this Speak Up Program.

I understand that if I violate any of the terms herein that I may be subject to discipline as provided for in the Student Disciplinary Procedures. Furthermore, should I engage in any inappropriate behavior I understand I may be dismissed from further participation herein which may result in my needing to take measures to find alternative means of transportation to return to my home.

Signature*

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