Jan 24-25 Engineers' Weekend

Participant's Contact Information

First Name

Last Name

Preferred Name (will be used for name tag)

Gender

Female

Male

Participant's Email Address

Confirm Email Address

Home Phone Number

Mobile Phone Number (if applicable)

Mailing Address

Country

Street

City

Region

Postal Code

Birthdate

Education Information

Student Type

Current High School (it may be helpful to search by your school city)

Hidden: CEEB

Hidden: School Priority

Hidden: School Level

High School Graduation Year

Hidden: month

Hidden: Concatenate Month/Year

Planning Information

Select an adult t-shirt size (for participant)

Small

Medium

Large

X-Large

Haven’t been to campus before?

We recommend attending the Academic Spotlight Day sponsored by the Admissions Office, 9:00 AM until 3:30 PM. Guests who remain on-campus for Engineers’ Weekend will receive dinner vouchers for you and your guests.

Are you interested?

Haven’t been to campus before?

We recommend attending the Academic Spotlight Day sponsored by the Admissions Office, 9:00 AM until 3:30 PM. Guests who remain on-campus for Engineers’ Weekend will receive dinner vouchers for you and your guests.

Are you interested?

Yes

No

Haven’t been to campus before?

We recommend attending the Open House sponsored by the Admissions Office before the start of Engineers' Weekend. Guests who remain on-campus for Engineers’ Weekend will receive dinner vouchers for you and your guests.

Are you interested?

Haven’t been to campus before?

We recommend attending the Open House sponsored by the Admissions Office before the start of Engineers' Weekend. Guests who remain on-campus for Engineers’ Weekend will receive dinner vouchers for you and your guests.

Are you interested?

Yes

No

Does participant have any dietary restrictions or special medical conditions that we should be aware of?

Yes

No

Please explain.

If you have pre-arranged your overnight stay please provide your student host's name, dorm, room number and host's cell number.

Additional comments, questions or requests

Waivers

Liability Waiver

The student named above has my permission to participate in Engineers' Weekend at Messiah University as a voluntary activity. I certify that the student is in good physical condition and is fully able to participate. I understand participation may involve significant physical activity and while reasonable safety measures will be taken, I also understand that participation could result in injury.
I also understand that my student will be sleeping overnight in a student residence belonging to Messiah University during this activity. If so, I give my permission for my student to do that.
I assume all risk related to the student participation and release Messiah University, its employees, agents, officers, students, and volunteers from all liability, claims, expenses and actions which may arise from injury or harm to the student as a result of participation in the activity.

Medical Waiver

In the event of a medical emergency, I authorize Messiah University to designate a physician or hospital or emergency personnel to provide medical care (including hospitalization, if necessary) to the student, and release Messiah University from any liability for injury or harm to the student which may result from this medical care. This includes authorizing the Medical Personnel to order X-rays, routine tests, or treatment; to release any records for insurance purposes; and to provide or arrange necessary related transportation for the participant.
I understand that responsibility for payment for such medical care will be mine.

Authorization to Record, Publish, and Broadcast

I hereby allow representatives of Messiah University and the Department of Engineering to photograph me, the participant and/or my property and permit them to use and publish the same (including use and publication with my name or no name, use in the form taken or with intentional or unintentional alterations, and for purpose of public information, illustration, Internet use, and in the advertising of Messiah's services).
I understand I may ask questions about the photos and publications; the photos are the property of Messiah University and are not for sale; I may withdraw my consent in writing at any time.

Participant's Age

Primary Parent/Guardian First Name

Primary Parent/Guardian Last Name

Primary Parent/Guardian Phone Number

Primary Parent/Guardian Email

Primary Parent/Guardian Relationship to Student

I agree that I have read and understand the above waiver information detailed in this form.

Signature of Parent or Guardian

Emergency Contact Information

PRIMARY CONTACT

Primary Emergency Contact's Name

Primary emergency contact's MOBILE phone

Primary emergency contact's HOME phone

Primary emergency contact's WORK phone

SECONDARY CONTACT

Secondary emergency contact's NAME

Secondary emergency contact's preferred phone number

By submitting this form, I agree to phone calls and/or text messages from or on behalf of Messiah University at the phone number provided on this form, including my mobile phone number. I understand that these calls may be generated using automated technology. I further understand that I can opt-out of these communications by emailing UNSUBSCRIBE to Admissions@messiah.edu.