University of Iowa Summer Journalism Workshops

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This completed online form will secure your spot
See workshop list to determine what your payment should be and mail to:
• Iowa Summer Journalism Workshops
• 100 Adler Journalism Building, Room E346
• Iowa City, IA 52242
If you would prefer to send in a hard copy of your registration and medical forms, you can download the PDF here. Please do not register both online and by mail. Only ONE completed registration is necessary.

Full registrations completed by June 1 receive the early bird rate. The registration deadline is June 14.

*Refunds can be made without penalty only until June 28. No refunds will be made once the Workshops begin.

Student Registration Form

The 2013 workshops are July 14-18.

Workshop:	Since all workshops are held at the same time, you may only choose one. Click here to learn more about each workshops. First number listed is cost before 6.1.13. Second is cost with a postmark of 6.1.13 or later. Cost includes room and board. Contact us for commuter rates. Click here if you will commute to campus each day. (Students not residing or eating on campus should deduct $100 from the above fees.) Parking on campus? (Add $75)
Student's name:
Address:
Phone:
Student cell phone:
Student email:
Parent email:
Gender:
Year of graduation:	(Students who have just completed grades 8, 9, 10, 11 or 12 may attend the Workshops.)
T-shirt size:
School Name:
School Address:
School Phone:
Adviser:
Roomate Request:	Roommate requests will be honored when possible. Students who do not make a request will be matched with students who are of the same gender, are in the same age range and attend different schools to provide workshoppers with a broader social experience. -------------------------------------------------------- Emergency Contact and Liability information
Emergency contact #1
Emergency contact #2	Release of Liability In consideration of the High School Journalism Student Workshops of the University of Iowa granting the student permission to participate in the High School Journalism Workshop activity, as a parent or guardian I do hereby agree to the following: The undersigned realizes that participation in program activities involves some risks and dangers which must be shared by both the University and the student and parents. I release the Iowa State Board of Regents, the University of Iowa, the High School Journalism Student Workshops and their offices, employees, and agents, and all instructors and all participants in said High School Journalism Student Workshops program from all liability, including claims and suits at law or in equity, or injury, fatal or otherwise, which may result from the student taking part in High School Journalism Student Workshop activities. The undersigned agrees that his/her child will comply with all program rules, instructions and directions from staff members of the program, and assumes the risk and responsibility for any consequent expenses, property damage or personal injury arising from his/her child’s failure to comply with those rules, instructions and directions. In compliance with program rules, the undersigned agrees to the release of Workshops student performance records to appropriate school personnel and guardians. It is agreed that if any damage, injury or illness occurs, it is understood that the undersigned has personal property, health and accident insurance, or the equivalent, and that such insurance coverage will first bear the financial burden of any claim or costs associated with loss, damage, injury, or accident, prior to any claim being made against the University of Iowa. You agree that any and all claims will first be submitted to the undersigned’s personal insurer for payment, and agree to waive all rights of subrogation against the University for any claims paid under such insurance. In signing this release of claims, I hereby acknowledge and represent: (a) That I have read this document in its entirety, understand it, and sign it voluntarily, (b) That I am of legal age, and (c) That this release of claims is a contract between these parties and its terms are contractual and not a mere recital.
Parent/guardian's name:
Parent/guardian electronic signature	Typing your name in the above box counts as your signature.
Date:
Parent/guardian address:
Parent/guardian cell or home phone:
Parent/guardian work phone:
Parent email:
Student signature	Typing your name in the above box counts as your signature. -------------------------------------------------------- Medical and insurance information
Participant's name:
Gender:
Date of birth:	-------------------------------------------------------- Health history List any previous and present health problems and dates of occurrence (major illness, allergies, asthma, diabetes, etc.):
Please list:
Current medications:
Drug sensitivies:
Does student wear an ID band or carry a card?
Date of last Tetanus booster:	-------------------------------------------------------- Who should we contact in case of medical emergency?
Emergency contact #1
Emergency contact #2	-------------------------------------------------------- Treatment, cost and disclosure Permission to treat, agreement to assume cost related to the treatment, and authority to disclose medical information to insurance company for the purpose of claim. I hereby authorize and give my consent to the health authorities of The University of Iowa or any licensed health professional to perform upon or administer any reasonable, necessary treatment to:
Student's name:	In the case of psychiatric and/or psychological emergencies, involving psychological treatment, parental authorization for treatment beyond that responsive to the emergency will be requested. I also give permission to administer whatever anesthetic may be necessary or advisable during medical or surgical procedures. This authorization is intended to include emergency treatment, immunizations, injections, and minor operations and procedures. I agree to assume all costs related to such treatment. I authorize my insurance company to pay benefits to The University of Iowa Student Health Service and/or The University of Iowa Hospitals and Clinics. Also, I authorize the disclosure of medical information to my insurance company for the purpose of this claim. This permission is good only while the student is attending the program at the University of Iowa and only until the student has attained his/her eighteenth birthday.
Parent/guardian's name:
Parent/guardian electronic signature	Typing your name in the above box counts as your signature.
Date:	-------------------------------------------------------- Insurance information
Policy holder's name
Policy number
Insurance company name/address
Other health and accidental coverage (Medicare, etc.)	-------------------------------------------------------- Release of liability In consideration of the High School Journalism Student Workshops of the University of Iowa granting the student permission to participate in the High School Journalism Workshop activity, as a parent or guardian I do hereby agree to the following: The undersigned realizes that participation in program activities involves some risks and dangers which must be shared by both the University and the student and parents. I release the Iowa State Board of Regents, the University of Iowa, the High School Journalism Student Workshops and their offices, employees, and agents, and all instructors and all participants in said High School Journalism Student Workshops program from all liability, including claims and suits at law or in equity, or injury, fatal or otherwise, which may result from the student taking part in High School Journalism Student Workshop activities. The undersigned agrees that his/her child will comply with all program rules, instructions and directions from staff members of the program, and assumes the risk and responsibility for any consequent expenses, property damage or personal injury arising from his/her child’s failure to comply with those rules, instructions and directions. In compliance with program rules, the undersigned agrees to the release of Workshops student performance records to appropriate school personnel and guardians. It is agreed that if any damage, injury or illness occurs, it is understood that the undersigned has personal property, health and accident insurance, or the equivalent, and that such insurance coverage will first bear the financial burden of any claim or costs associated with loss, damage, injury, or accident, prior to any claim being made against the University of Iowa. You agree that any and all claims will first be submitted to the undersigned’s personal insurer for payment, and agree to waive all rights of subrogation against the University for any claims paid under such insurance. In signing this release of claims, I hereby acknowledge and represent: (a) That I have read this document in its entirety, understand it, and sign it voluntarily, (b) That I am of legal age, and (c) That this release of claims is a contract between these parties and its terms are contractual and not a mere recital.
Parent/guardian's name:
Parent/guardian electronic signature	Typing your name in the above box counts as your signature.
Date:
Parent/guardian address:
Parent/guardian cell or home phone:
Parent/guardian work phone:
Student signature	Please make sure you have completed every field before clicking "Submit." If this form has been properly completed, there is nothing else we need from you at this time. Thank you for choosing the Iowa Summer Journalism Workshops. We'll see you Sunday, July 22. Please make all checks payable to Iowa Summer Journalism Workshops.