Participant's First Name *

 
Participant's Last Name *

 
Gender *


 
Date of Birth *

 
Participant's Email Address *

 
Confirm Participant's Email Address *

 
Participant's Main Phone Number *

If the participant is a Minor who doesn't have a personal mobile phone number, please list the Main Phone Number of a Parent or Guardian in order to reach the participant.
 
Can you confirm the participant will be able to participate during the entire duration of the Workshop? *

The mLab Workshop will operate from Tuesday, April 17th through Friday, April 20th, 2018.
     
 
Ethnicity *


 
Participant's Education Level *


 
Does the participant speak or read in any of the following languages?


 
Does the participant speak or read in any of the following languages?


 
Does the participant's have any allergies or medical conditions?

If yes, please list below along with medication taken to alleviate allergies or medical condition.
 
Check all of the equipment the participant has experience with;*


 
Check out all of the following programs the participant has experience with;*


 
Emergency Contact: First Name *

 
Emergency Contact: Last Name *

 
Emergency Contact: Residential Address *

 
Emergency Contact: Email Address *

 
Emergency Contact: Confirm Email Address *

 
Emergency Contact: Phone Number *

 
Legal Agreement *

I understand that participation in a mLab (Mbadika Laboratory) Workshop is voluntary and the program is being offered to local area students throughout Winter and Spring 2018 as strictly a not-for-profit educational opportunity through the Hawthorne Youth Community Center (HYCC) by Mbadika, Inc., Ministry of Supply (Mos), AFFOA, as well as any individuals or organizations affiliated with those previously named.

As the parent or legal guardian of the aforementioned applicant, if selected, I am releasing Mbadika, Inc., the Hawthrone Youth Community Center (HYCC), Ministry of Supply (Mos), AFFOA, and their representatives or affiliates from any wrongdoing during the course of this workshop. This includes any additional costs (including but not limited to transportation, food, beverages, materials, etc.) as well as personal or bodily harm accrued through participation in Hawthrone Youth Community Center (HYCC) activities, programs, and events including mLab (Mbadika Laboratory) Workshop.

In addition, I realize the program is a subsidized workshop offered by Mbadika, Inc., Hawthorne Youth Community Center (HYCC), Ministry of Supply (MoS), and AFFOA in order to provide an invaluable, hands-on educational experience for to local area students. Hence, I agree to pay any required participation fee or forfeit an opportunity to participate in a mLab (Mbadika Laboratory) Workshop if selected.

Further, I understand that if a student is found to be disruptive to the learning environment during a mLab (Mbadika Laboratory) Workshop, they will be asked not to return, continue, and complete any current or additional sessions and no refund will be given.

I also grant permission to Mbadika, Inc., Hawthorne Youth Community Center (HYCC), Ministry of Supply (MoS), and the AFFOA, and their affiliates to film and otherwise document the aforementioned applicant's participation for promotional and commercial purposes.

By selecting 'I Accept', I acknowledge and accept all of the above terms as well as stated. By selecting 'I Don't Accept', I am acknowledging that I do not accept the above terms and will discuss alternative arrangements with the Mbadika, Inc. and Hawthorne Youth Community Center (HYCC) Administrative Team but do acknowledge this may impact my participant's ability to engage in the program as described.
I understand that participation in a mLab (Mbadika Laboratory) Workshop is voluntary and the program is being offered to local area students throughout Winter and Spring 2018 as strictly a not-for-profit educational opportunity through the Hawthorne Youth Community Center (HYCC) by Mbadika, Inc., Ministry of Supply (Mos), AFFOA, as well as any individuals or organizations affiliated with those previously named.

As the parent or legal guardian of the aforementioned applicant, if selected, I am releasing Mbadika, Inc., the Hawthrone Youth Community Center (HYCC), Ministry of Supply (Mos), AFFOA, and their representatives or affiliates from any wrongdoing during the course of this workshop. This includes any additional costs (including but not limited to transportation, food, beverages, materials, etc.) as well as personal or bodily harm accrued through participation in Hawthrone Youth Community Center (HYCC) activities, programs, and events including mLab (Mbadika Laboratory) Workshop.

In addition, I realize the program is a subsidized workshop offered by Mbadika, Inc., Hawthorne Youth Community Center (HYCC), Ministry of Supply (MoS), and AFFOA in order to provide an invaluable, hands-on educational experience for to local area students. Hence, I agree to pay any required participation fee or forfeit an opportunity to participate in a mLab (Mbadika Laboratory) Workshop if selected.

Further, I understand that if a student is found to be disruptive to the learning environment during a mLab (Mbadika Laboratory) Workshop, they will be asked not to return, continue, and complete any current or additional sessions and no refund will be given.

I also grant permission to Mbadika, Inc., Hawthorne Youth Community Center (HYCC), Ministry of Supply (MoS), and the AFFOA, and their affiliates to film and otherwise document the aforementioned applicant's participation for promotional and commercial purposes.

By selecting 'I Accept', I acknowledge and accept all of the above terms as well as stated. By selecting 'I Don't Accept', I am acknowledging that I do not accept the above terms and will discuss alternative arrangements with the Mbadika, Inc. and Hawthorne Youth Community Center (HYCC) Administrative Team but do acknowledge this may impact my participant's ability to engage in the program as described.
     
 
By typing your legal full name in the box below, I acknowledge who has accepted all of the above terms as well as stated. *


If the participant is a minor, the legal Parent or Guardian must type their full name in the box below.
 
Today's Date *

Thanks for completing this typeform
Now create your own — it's free, easy, & beautiful
Create a <strong>typeform</strong>
Powered by Typeform