Registration Form

NEBRASKA ACADEMIC DECATHLON
Student Registration Form
2010-2011

      I, now a student at
                      First Name                         Initial                            Last Name

   in Grade    and living at,
                                   Name of your High School


             Your Street Address                                    Apt. #                                           Your email address


                       City                                                   ZIP Code                                     Telephone Number


                               Parent / Guardian                                                            Parent or Guardian email address


                     2nd Parent / Guardian  (Optional)                                           2nd Parent / Guardian email address

hereby request participation in the Academic Decathlon Competition at the Regional level on January 17, 2009 and at the State level on February 20-21, 2009 (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 in connection 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 second 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.

Now you only have three steps to go:

1. PRINT THIS FORM TO COLLECT THE NEEDED SIGNATURES

2. GIVE THE SIGNED FORM TO YOUR COACH

3. YOUR TENTATIVE REGISTRATION TO THE NEBRASKA ACADEMIC DECATHLON.