Careers in Construction Registration

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Student Information
Student Name * Required
First Last
Student Address * Required
Street Address Address Line 2 City State ZIP Code
Student Age * Required
Student grade - Fall 2020 * Required
Student School * Required
Student T-Shirt Size * Required
Construction Industry MOST interested in * Required
Parent/Guardian Information
Parent/Guardian Name * Required
First Last
Parent/Guardian Phone * Required
Parent/Guardian Email * Required
Student Emergency Contact Information
Student Emergency Contact Information * Required
- Same as Parent/Guardian Information listed above
- Different from the Parent/Guardian Information listed above
Emergency Contact Name * Required
First Last
Emergency Contact - Relation to Student * Required
Emergency Contact Phone * Required
Participation and Media Release
I am the parent or guardian of the student whose name appears below and I have authority to make legal decisions for the benefit of this child.
I recognize that work-based learning opportunities of this nature have a risk of lost or stolen property, injury or even death during transportation to, from, on-site, and during the activities. I, on behalf of the child and for myself, waive any and all claims of liability arising from the child’s participation in this opportunity, including claims against the following parties (and their employees, contractors, and volunteers): Northwest Iowa Community College, Interstates, the school and school district that the child attends, and the employer who hosted the work-based learning opportunity.

I agree to defend, hold harmless, and indemnify Northwest Iowa Community College, Interstates, the school, and the school district that the child attends, and the employer who hosted the trip (and their employees, contractors, and volunteers) from and against any and all claims of liability that derive from claims that I or my child make against any other parties from this work-site opportunity.

I give my consent to have Northwest Iowa Community College staff member contact my son or daughter at some future date to review their career development.

Media: I agree to allow my child’s photograph, video tape or motion picture image that includes his/her name or likeness or any recording that includes his/her voice to be used in marketing materials to promote the Northwest Iowa Community College Intermediary Network program. I understand that my child’s photo/image will only be used in a positive manner in publications, print advertising, promotional materials or any other media to inform others about the career exploration activities coordinated by the Intermediary Network program and the school districts.
- Yes -- I will allow my child’s image/comments to be used by Northwest Iowa Community College and Interstates.
- No -- I will not allow my child’s image/comments to be used by Northwest Iowa Community College and Interstates.
Signature
Parent/Guardian Signature * Required
By signing below, I authorize my child to participate in the Careers in Construction activity. (Required if participant is under 18 years of age)
Date - must be mm/dd/yyyy format * Required
Date Format: MM slash DD slash YYYY
Northwest Iowa Community College programs provide equal opportunity to all persons regardless of sex, race, age, creed, color, national origin, religion, sexual orientation, marital status or disability.
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Careers in Construction Registration

Student Information

Parent/Guardian Information

Student Emergency Contact Information

Participation and Media Release

Signature

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