Careers in Construction Registration Listen If you have already registered, please click here. Student InformationStudent Name * Required First Last Student Address * Required Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Student Age * RequiredStudent grade - Fall 2020 * Required6th7th8thStudent School * Required Construction Industry MOST interested in * RequiredCarpentryPlumbingHVACElectricalN/AParent/Guardian InformationParent/Guardian Name * Required First Last Parent/Guardian Phone * RequiredParent/Guardian Email * Required Student Emergency Contact InformationStudent 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 * RequiredParticipation and Media ReleaseI 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. SignatureParent/Guardian Signature * RequiredBy 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 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.CAPTCHA
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