The Verizon Minority Male Makers Program

SUMMER STE M
PROGRAM
The Verizon Minority Male Makers
Program-Directed by the
Jun e 27 th to July
22 nd
University of the District of Columbia
The Verizon Minority Male Makers Program-Directed by the University of
theDistrictofColumbiaisofferingafreeall-expensespaid4-weekintensive
summer program designed to engage students in high quality, hands-on
learning in Science, Technology, Engineering andMath (STEM) in order to
increaseaccesstoSTEMfocusedcareersandhighereducation.Inaddition
tothesummerprogram,studentswillreceiveamentorandparticipatein
STEMworkshopsduringtheacademicyearatUDCandhostsitesacrossthe
District!
ForMoreInformation
Contact
Dr.JamesMaiden
202274-5768
[email protected]
TheprogramisforyoungmalesofAfricanAmericanandHispanicdescent
in grades 6th– 8th. Those selected will have the opportunity to learn 3D
printing,Appdevelopment,androbotics.Therewillbecompetitions,prizes
andexcitingfieldtrips.
Give your child the opportunity to excel in the STEM area by receiving
advance training from UDC academic leaders in the field. The Verizon
MinorityMaleMakersprogramwascreatedbyVerizon,andisdirectedby
theUniversityofDistrictofColumbia.
aim
m
a
r
g
l
oo
h
sc D
e h3 l
l
dd oug goa y
i
m hr
e en b
y
t
h
t
i
t
or ers ly, ty m
n
of
mi mak ate ori
s
n
e
n
io
b l nd ltim m i
t
a
a
a
en rs nt. U n of d
ov or
n
o
o
f
n
s t eat pme ra tio y a e in res
m
r
a i e c e lo ne log ld th utu
m
a om dev ge hno bui er f
r
og b ec pp new tec to ig ht
r
a
s
p
e s to n d er a long kill e br ies.
h
T le n a ow ife p s at m il
ma sig mp m l shi cre r fa
r
e
i
e
e
o
d to
th n eu d t the
g
s
i vin
re an nd
p
i
g tre row s a
e
e n mor e lv
to ems
th
T
di he
m sc cu
od ip rr
el lin icu
lin es lu
g, : a m
de pp wi
s i d ll c
gn es o
an ign ver
d an a
pr d ra
in d ng
tin ev e
g; el of
an op ST
d me EM
ro n
bo t; 3
t ic D
s.
h
t
es
o
td ?
a
Wh ieve
ach
o
t
o
r
p
e
W
ob h a
ta tsk
in il
? ls
w
ill
th
e
st
ud
en
ts
Part
icipa
nts:
A
frica
n A m
erica
n
a n d
Hisp
Grad
an i c
es:6 th
Mid
t h r o
dleS
D a te
u g h th
ch oo
:Jun
8 e27 th
lBo
ys
t
4 W
h
r
o
eeks
ugh
July
-M
22 nd
ond
ayth
Tim
roug
Cu r r
e:9: hFr
iculu
3
iday
0
a
m:R
m to
obo
3
:
30p
Co l l
tics, m
ege
Ap p
Rea
D
evel
dine
opm
ssan
e n t,
dEn 3 D tr e p
Prin
rene
ting
uria
Field l
Wor
Trip
ks h o
s
ps
Me n
torin
Free
M a
g
th T
utor
ingD
urin
Lu n c
gSch
h I n
ool
*Met
clud
r or a
ed
ilCa
*T r a
rdsw
velI
illbe
nclu
pro
vide
ded dto
p
artic
ipan
t
swh
one edt
rans
p or t
atio
n.
REGISTRATIONFORM
Theselectedparticipantswillattendtheprogramaccordingtothefollowingschedule:
ProgramrunsJune27ththroughJuly22nd-MondaythroughFriday,9:30am–3:30pm
Participationintheprogramisvoluntary.Ifyourchildisselected,heisexpectedtoattendeverydayfor
the full four weeks. This packet contains the forms that must be completed and returned before the
studentwillbeallowedtoattendsummerprogram.
1.
2.
3.
4.
5.
6.
StudentInformation
ParentalConsent,Release,HoldHarmlessandAuthorizationToReproducePhysicalLikeness
VerizonGeneralReleaseFrom
ProgramEvaluationandResearchReleaseForm
ParticipantMedicalReleaseForm
Field Trip Release Form –(A Field Trip Release Form will be provided prior to the date of the
fieldtrip)
PleasemakesurethatallfiveformsarecompletedandreturnedtousbyJune15th.Completedforms
maybemailed,faxed,oremailtotheattentionof:
Dr.JamesMaiden
AssistantDeanofStudentAffairs
TheUniversityoftheDistrictofColumbia
4200ConnecticutAvenue,NW
Building41,Suite405
Washington,DC20008
[email protected]
Fax:202274-5589
Phone:202274-5768
1. STUDENTINFORMATION
Pleasemakesuretocompleteallrequiredinformationandprintclearlyonthisform.Missinginformation
may cause delays in processing your child’s application and could cause him not to be eligible for the
program.
ParticipantInformation
FirstName:________________________MiddleInitial_____LastName:___________________________
Phone:______________________Email:_____________________________________________________
Homeaddress_________________________________City________________State___Zip____________
School:_____________________________________________________Grade(asofFall2016):_______
Birthdate:_____________________
Ethnicity:(Checkone)___Black/AfricanAmerican
___Hispanic/Latino
T-ShirtSize:(Checkone) YouthSize:___SM___MED___LG
Parents/GuardianInformation
Parents/GuardianFirstName:_________________MiddleInitial____LastName:___________________
Primarycontact:________________________Relationshiptoparticipant:_________________________
Homeaddress(Ifdifferent)____________________________City_________________________________
State__________Zip____________
CellPhone:___________________________Email:___________________________________________
Secondarycontact:_______________________Relationshiptoparticipant:_________________________
CellPhone:___________________________Email:___________________________________________
IconfirmthatIamtheParent/Guardianofthestudentparticipatingintheprogram:
______________________________________________________________________________________
Parent/guardian’snameandsignature
Date
2.CONSENT,RELEASE,HOLDHARMLESSANDAUTHORIZATIONTOREPRODUCEPHYSICALLIKENESS
I grant permission for my son (Please Print) _______________________________________________ to
participateinTheVerizonMinorityMaleMakersProgramsummerprogram.
Iunderstandthatinordertoparticipateinthisprogram,mysonmustabidebytheestablishedrulesand
codesofconductestablishedbytheprogramstaff.TheVerizonMinorityMaleMakersProgramreserves
the right to dismiss a child from the program due to that child's disruption of the program, failure to
followsafetyorprograminstructions,andanyotherdisruptivebehavior.
I understand and agree to assume any and all risks associated with the summer program activities. I
understand that even with careful supervisions, accidents can occur. I recognize this risk and agree to
release and forever discharge all the volunteers, staff and the schools where such activities take place
fromanyandallclaims,demands,damages,actions,causesofaction,orsuitsofanykindornature,and
particularly on account of all injuries, both to person or property, at any time or any place relating to
participationintheprogram.
______________________________________________________________________________________
Parent/guardian’snameandsignature
Date
3.GENERALRELEASE
I grant Verizon Communications Inc., its subsidiaries, successors, assigns, and licensees (collectively “Verizon”) the following
rights:
1.IgrantVerizontherighttotakephotographsandvideosofmeandmylikenessandrecordorotherwisetakemyvoicefor
testimonialsandotherstatements(“Photography”)onthedateandatthelocationlistedbelow.
2.IalsograntVerizontherighttoeditandusethePhotographyinanywaywhatsoever,foranypurpose,andinanymanner
andmedium,includingbutnotlimitedto,advertising,publicityorpromotionalmaterial,inprint,video,television,radio,orany
othermedia,electronicorotherwise,includingwebsitesandtheInternet,atanytimeortimesthroughouttheworld,touse
quotationsandsoundtrackrecordingsofmeormyvoice,includingtherighttosubstitutethevoiceofanotherperson(s)formy
voice, to use my name or a fictitious name and biographical and other information, accurate or fictitious, concerning me in
connectionwiththeuseofthePhotography.
3.IwaiveanyrighttoinspectorapprovethePhotographyorhowthePhotographyisusedandfurtherwaiveanyclaimthatI
mayhavewithrespecttoitsuse.
4.IacknowledgethatIwillnotreceiveanycompensationotherthananypublicitythatImayreceiverelatingtotheuseofthe
Photography.
5. I forever release and discharge, and agree to hold harmless Verizon and its directors, officers, agents, employees,
shareholdersandrepresentativesfromanyandallliabilityforanyviolationofanypersonalrights(includingrightofprivacyand
rightofpublicity),intellectualpropertyrightsoranyotherrightswhichImayhavearisingoutoforinconnectionwithVerizon’s
useofthePhotography
6.IrepresentandwarrantthatIamoffullageandhaveeveryrighttocontractinmyownnameintheaboveregard.This
agreementshallbebindinguponme,myheirs,legalrepresentativesandassigns.
Locationanddate:_____________________________________________________________________
Iherebyagreeandconsent:
PrintedName
Signature
Address
Date
Ifaminor:Iamthe(parent/legalguardian)ofthenamedminor.Iagreeandconsenttotheforegoingonbehalfoftheminor
andpersonallyjoininthewarrantiesandrepresentationsabove.IalsoagreetoindemnifyandholdharmlessVerizonagainst
anyclaimstheminormaymakeasaresultofVerizon’suseofthePhotographyasdescribedabove.
PrintedNameof
Minor
PrintedNameof
Parent/LegalGuardian
SignatureofParent/Legal
Guardian
Address
Date
3.Exenciónderesponsabilidadgeneral
Pormediodelpresente,yo,elabajofirmante,otorgolossiguientesderechosaVerizonCommunicationsInc.,140
WestStreet,NewYork,NewYork10007,sussubsidiarias,sucesores,cesionariosyconcesionarios(colectivamente,
“Verizon”):
OtorgoaVerizonelderechoylaautorizaciónirrevocablesyabsolutospararegistrarmiimageny/omivozmediantefotografíafija,película,
cintadevideo,grabacionesdesonidosocualquierotromedio(enadelante,“fotografía”)enlafechayellugarquesemencionanmás
adelante.
TambiénotorgoaVerizonelderechoaeditarsegúnsucriterio,usar,publicar,distribuir,exhibir,obtenerdichafotografíayotorgarlicencias
deellaaterceros,demaneratotaloparcial,individualmenteojuntoconotrasfotografías,imágenesocualquiermaterialsujetoaderechos
deautor,concualquierfinalidad,decualquiermanerayporcualquiermedio,comomaterialesdepublicidad,propagandaopromoción,entre
otros,enformaimpresa,porvideo,televisión,radioocualquierotromediodecomunicación,pormedioselectrónicosodeotramanera,
comositioswebeInternet,encualquiermomentoyentodoelmundoaperpetuidadsinlaobligacióndeinformarmealrespecto,aobtener
derechosdeautordedichafotografíaensupropionombreodeotramanera,ausaroautorizarelusodecitasygrabacionesdesonidosmíos
odemivoz,incluidoelderechoareemplazarlavozdeotrapersonaodeotraspersonaspormivoz,ausarminombreounnombreficticioe
informaciónbiográficaodeotrotipo,precisaoficticia,respectodemipersonaorelacionadaconelusodedichafotografía.
Pormediodelpresenterenuncioatododerechoarevisaroaprobarlafotografíaoelmaterialeditorialoimpresoquepuedautilizarsejuntocon
ellos;asimismorenuncioacualquierreclamaciónquepudieratenerconrespectoalusoeventualalquepudieranestarsujetos,
independientementedequeyotengaonoconocimientodeluso.
AceptoqueVerizon,olosagentesdeVerizon,poseenlatitularidaddelosderechosdeautorsobrelafotografía.Sirecibieraunacopia
impresa,ennegativoodeotrotipodedichafotografía,nopodréautorizaraningunaotrapersonaaquelause.
Pormediodelpresentedeclaroygarantizoqueestaasignacióndederechosnocontradicedeningúnmodocualquiercompromisoqueyo
tengaactualmente.Hastalafechanoheautorizado(conunaautorizaciónquesigaenvigor),niautorizarénipermitiréelusodeminombre,
voz,cita,fotografíaoimagenenrelaciónconlapublicidadylapropagandadecualquierproductooservicioquepertenezcaalacompetencia
oqueseaincompatibleconlosproductososerviciosqueofreceVerizon.
Aceptoquenorecibirécompensaciónalgunaporotorgarlosderechosincluidosenelpresentedocumento.
Pormediodelpresente,eximoyexoneroparasiempreyaceptolibraraVerizonysusdirectores,directivos,agentes,empleados,accionistas
yrepresentantesdetodaresponsabilidadcausadaporlaviolacióndelosderechosindividuales(incluidoelderechoalaprivacidadyel
derechoalapropiaimagen),losderechosdepropiedadintelectualocualquierotroderechoquepudierateneryquesurjadelusoporparte
deVerizondelafotografíatalcomosedescribióanteriormente,oestérelacionadocondichouso,entrelosqueseincluyenerrores,aspecto
borroso,distorsión,alteración,ilusiónópticaoauditivadelafotografía.
Pormediodelpresentedeclaroygarantizoquesoymayordeedadyquetengoelderechodecelebrarelcontratoconrespectoaloanterior
ennombrepropio.Elpresenteacuerdoserávinculanteparamí,misherederos,representanteslegalesycesionarios.Asimismodeclaroque
heleídoestaExenciónderesponsabilidadgeneralantesdefirmarlayquecomprendosustérminos.
Lugaryfecha:______________________________________________________________________________________________________
Título y n.° de proyecto: ______________________________________________________________________________________________
Información y firma de la persona fotografiada:
Nombre
(en letra de imprenta)
Firma
Dirección
Fecha
En caso de ser menor de edad: Soy (el padre/la madre/tutor legal) del menor indicado a continuación. Acepto la información precedente en
nombre de dicho menor y personalmente adhiero a las declaraciones y garantías expuestas anteriormente. Asimismo, acepto indemnizar y librar
de toda responsabilidad a Verizon con respecto a las reclamaciones que el menor pudiera hacer como resultado del ejercicio que Verizon haga
4.PROGRAMEVALUATIONANDRESEARCHRELEASEFORM
The Verizon Minority Male Makers Program evaluates all its programs to make sure that they are
effective, and to improve them, as needed. The evaluations and results are reviewed by those who
oversee the program. The evaluations and results may also be used for scholarly research to increase
minoritymales’entranceintotheSTEMfield.
During the time your son is in The Verizon Minority Male Makers Program, he may be observed by
evaluatorsandresearchersduringdifferentprogramactivitiesandmaybeaskedtogivehisfeedbackand
opinionsinresponsetoquestionnairesorsurveys,infocusgroups,and/orininterviews.
Your child’s participation is VOLUNTARY; he does not have to participate in these activities, and can
choosenottoanswercertainquestions,ordecidenottoparticipate,orwithdrawfromparticipationat
anytime.
Theseevaluationassessmentsarenotanonymous,soyourchild’snamewillbeincludedontheformsthat
areusedfortheevaluation(s);however,allinformationandresultswillbekeptstrictlyCONFIDENTIALand
personal data will not be stored. Information identifying your child’s name will be removed before the
results are analyzed and given out. Participants’ names will never be used in any report or publication.
DatasharedwithVerizonwillbeinaggregateandnoindividualleveldata(oridentifyinginformation)will
beshared.
Finally, The Verizon Minority Male Makers Program reserves the right to use personal information (for
example, permanent address, phone number, and/or email address) to contact participants after the
program to gather information about their career or educational successes. Participants’ personal
informationwillneverbedistributedoutsideofTheVerizonMinorityMaleMakersProgram–Directedby
TheUniversityoftheDistrictofColumbia;willbekeptcompletelyconfidential;willbeusedbyauthorized
personnelonly;andwillbestoredinpasswordprotectedandsecureserversordatabases.
If you have any questions about this evaluation or about evaluation participants’ rights, please contact
JamesMaiden,[email protected].
ByauthorizingyourchildtoparticipateinTheVerizonMinorityMaleMakersProgram,youareagreeingto
the contents of this parental permission form – and indicating that you have read and understand the
information above and allow your child to participate in the evaluation part of this program. When
evaluationassessmentsarepresentedtoparticipantsintheprogram,yourchildwillbeinformedabout
theevaluationstudyandabouthisrightsasaparticipant.Atthattimeyourchildwillbeaskedtoprovide
hisagreementtochoosetoparticipateintheassessment.
______________________________________________________________________________________
Parent/guardian’snameandsignature
Date
5.PARTICIPANTMEDICALRELEASEFORM-A
NameofChild’sPhysician_________________________________________________________________
PhysicianPhone________________________________________________________________________
MedicalInsuranceCo._______________________________Policy/Group_________________________
Does the participant have any health conditions (i.e. allergies, chronic conditions), prescribed
medications,orspecialcircumstances(i.e.religiousconvictionsorlegalarrangements)thatweshouldbe
awareof?
(Checkone)___NO___YES
Ifyes,pleaseexplainonback.
Pleasealsolistanymedication(s)theparticipantwillrequire(prescribedornot).
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Intheeventofanemergency,whenparentsoremergencycontactscannotbereached,TheVerizon
MinorityMaleMakersProgramhasmypermissiontotakemychildtothenearesthospital.(Checkone)
___NO___YES
Pleaseprovidetheinformationofaresponsibleadultwhomwecancontactinanemergencyifweare
unabletocontactyou.
______________________________________________________________________________________
Name Relationship
Homeaddress_____________________________________City_________________________________
State__________Zip____________
DayandEveningphone(d)____________________________(e)_________________________
Email________________________________________
5.PARTICIPANTMEDICALRELEASEFORM-B
I/We certify that the participant is in good health and hereby authorize the directors of The Verizon
Minority Male Makers Program to act for me/us, according to their best judgment, in any emergency
requiringmedicalattention.I/Weunderstandandagreethatinstructors,counselors,andstaffmayneed
to contact appropriate emergency medical providers regarding said minor. I/We give consent for any
medicaltreatment(i.e.,diagnostic,therapeutic,andsurgicalprocedures)thatsuchmedicalprovidersmay
deemnecessarywiththeunderstandingthatthecostofanysuchtreatmentwillbemy/ourresponsibility.
I/We understand that my/our consent will allow procedures to be promptly carried out so that no
unnecessary delays will occur with treatment. No operation will be performed, except in extreme
emergency,withoutme/usbeingcontactedandfullyinformedandconsentobtained.
______________________________________________________________________________________
Parent/guardian’snameandsignature
Date
6. FIELDTRIPRELEASEFORM
(AFieldTripReleaseFormwillbeprovidedtoparentspriortothedateofthefieldtrip)
Mychildhaspermissiontoparticipateinfieldtripswithchaperones,forsummerprogramactivities.
______________________________________________________________________________________
Parent/guardian’snameandsignature
Date