NEBRASKA ACADEMIC DECATHLON
Student Registration Form
2010 - 2011

First Name	Middle Name/Initial	Last Name
Name of your High School		Grade
Select A School... Adams Central Alliance Arlington Ashland-Greenwood Bancroft-Rosalie Battle Creek Beatrice Bellevue East Bellevue West Boone Central Brownell-Talbot Centennial Central Catholic Cody-Kilgore Cozad Creighton Prep Duchesne Academy Elkhorn Gretna Humboldt-Table Rock-Steinauer Hyannis Johnson County Central Kearney Lincoln Northeast Logan View Loup City Lourdes Central Norris Omaha Benson Omaha Bryan Omaha Burke Omaha Central Omaha North Omaha Northwest Omaha South O'Neill Pius X Plattsmouth Ralston Ravenna Seward Shelton Skutt Catholic St Cecilia Tekamah-Herman Wood River York		Select Grade... Senior Junior Sophomore Freshman
Your Street Address	Apt #	Your e-mail address
City	ZIP Code	Your Telephone Number
Parent/Guardian Name		Parent/Guardian Email Address
2nd Parent/Guardian (optional)		2nd Parent/Guardian email address (optional)

hereby request participation in the Academic Decathlon Competition at the Regional level on January 16, 2010 and at the State level on February 19-20, 2010 (if applicable).My parent/guardian, whose signature is shown below, and I hereby agree to follow the Competition Day rules and will accept the interpretations and decisions of the Competition Day Chairperson. In consideration of my participation in the Decathlon, my parent/guardian and I hereby grant to the United States Academic Decathlon, Inc., its state and local affiliates, and their respective licenses, successors and assignees (collectively 'Grantees'), the right to publish, use and copyright my name, voice, portrait, picture, photograph, biographical material and educational data, including without limitation my test results, in all media inconnection with the promotion/publicity for the Decathlon, or for other educational purposes in the discretion of the Grantees. We hereby release and agree to indemnify the Grantees from and against any and all liability arising out of the exercise of the rights granted by this release.

Signature of Student		Month          Day          Year
Signature of Parent/Guardian		Month          Day          Year
Signature of 2nd Parent/Guardian (optional)		Month          Day          Year

NOTE TO STUDENT AND PARENT/GUARDIAN: The Nebraska Academic Decathlon Program is required to use this form by the National Office of the United States Academic Decathlon. The information you provide on this form will not be given or sold to other organizations except as described below. Your test scores, identified specifically by your name, are only provided to the coach of your school's decathlon team. We do announce either perfect or near perfect test scores on a given event at the Awards Ceremony. Since we invite the media to the competition, your picture may be taken and used in the news coverage of the competition. All regular team members of the 1^st, 2^nd, and 3^rd place teams at each Regional and the State Final will earn a scholarship. The amount of the scholarship is dependent on our fund raising efforts and each recipient is notified of the amount(by letter) during the early part of July. A student has two years following his/her graduation from high school to claim the scholarship. A scholarship check is sent directly to the college/university selected by the student and will be written to BOTH the student and the college/university. Thus, the student will know when the scholarship check arrives because he/she will be called to endorse the check.