Buenas and Hafa Adai!

The University of Guam College of Natural & Applied Sciences, in collaboration with the University of Hawai‘i at Mānoa’s College of Tropical Agriculture & Human Resources’ GENE-ius Day Program, presents Guam GENE-ius! Dr Ania Wieczorek, and her team in Hawai‘I, have been critical to getting our program started here on Guam and we are grateful.

Guam GENE-ius will give your children the opportunity to learn more about the world of science through our fun, interactive, and thought-provoking hands-on activities and experiments in a university setting. The program will:

- Encourage young students to explore more fully the world of science
- Foster critical thinking and problem-solving skills
- Stimulate curiosity
- Build an overall passion for science

Guam GENE-ius will be offering the awesome science curricula provided by Hawaii’s Saturday GENE-iuses to grades 4-6 students on Guam. The program will run a series of seven (7) classes with two (2) identical sessions (morning and afternoon) every-other-Saturday. Each Saturday session will cover fun and exciting topics representing a wide range of science disciplines that include biology, space, earth science, and more! Guam GENE-ius is taught by trained, reliable, and dynamic instructors and staff who are knowledgeable in the field of science. The program will take place in and around the Agriculture & Life Sciences building of University of Guam, which houses classrooms and labs.

The cost of the entire 7-week program is $70 and classes start on timeat 10am-noon (morning) and 2pm-4pm (afternoon). Once the program starts; there will be no refunds for classes missed, sorry. First day of class is Saturday, January 13, 2018 and runs through March 31, 2018; the last Saturday is a graduation. Applications, with payment, are due Friday, January 5.

Get ready to embark on a series of science adventures! If you have questions, please call Ms Kamille Wang, the program manager, at 787-8159.

Guam Gene-ius ParticipantRegistration Form

StudentInformation

NameofStudent: ______

Age: ______DateofBirth: ______Gender:______

School:______

Address: ______

City: ______State: ______Zip: ______

PrimaryContactPhone: ______

StudentMedicalInformation

-Doesyourchildhaveamedicalorbehavioralconditionyouwouldliketomakeusawareof? YES NO

-Isthisconditionlife-threatening? YES NO N/A

Ifyouanswered ‘Yes’ toeitheroftheabovequestions, pleasestatetheconditionhere: ______

-Is your child currently under any medicationsforthismedicalorbehavioralcondition? YES NO N/A

If you answered ‘Yes’ to the above question, please state what medication the participant is currently taking: ______
Parents are required to administer any medications needed by the participant prior to the Guam Gene-ius event.

-DoesyourchildrequireanEpiPenduetosevereallergy? YES NO

-Doesyourchilduseaninhalerduetoasthma? YES NO

Parent/GuardianInformation

Primary Parent/Guardian

Name:______Relationship to Participant: ______

HomePhone: ______CellPhone: ______WorkPhone: ______

Email Address: ______

Address: ______

City: ______State: ______Zip: ______

Secondary Parent/Guardian

Name:______Relationship to Participant: ______

HomePhone: ______CellPhone: ______WorkPhone: ______

Email Address: ______

Address: ______

City: ______State: ______Zip: ______

LIABILITYRELEASEFOR GUAM GENE-IUS

Iunderstandthat, whileGuam Gene-iusiscommittedtothoroughsupervisionofalllabactivities, thereareinherentrisksinattendanceat the Saturday event. Iunderstandandassumeallassociatedrisksofpersonalinjuryorloss, bodilyinjury (includingdeath), damageto, loss, ordestructionofanypersonalpropertyoccurringinconnectionwithorarisingoutofParticipantstudent’sparticipationinGuam Gene-ius.

Iherebyreleaseanddischarge, indemnifyandholdharmlessTheRegentsoftheUniversityofGuam, abodycorporate, anditsmemberofficers, agents, employeesandanyotherpersonsorentitiesactingontheirbehalf, andthesuccessorsandassignsforanyandalloftheaforementionedpersonsandentities, againstallclaims, demands, costsandexpenses, andcausesofactionwhatsoever, eitherinlaworequity, arisingoutoforinanywayconnectedwithanylossand/orbodilyinjuryand/ordisability, arisingfromparticipationinGuam Gene-ius Day.

Iauthorize, inamedicalemergency, afterreasonableefforthasbeenmadetonotifyme, thatGuam Gene-ius DaystaffmayseekemergencyassistanceandmedicaltreatmentforParticipantstudentattheparent/guardian'sexpense. IcertifythatIhaveadequateinsurancetocoveranyinjuryordamageParticipantstudentmaycauseorsufferwhileparticipating, orIagreetobearthecostsofsuchinjuryordamagemyself.

Having had sufficient time to review and seek explanation of the provisions contained above, by agreeing to the terms of Guam Gene-ius and marking my initials, I voluntarily give consent and agree to the above Informed Consent, Permission, Release, Assumption of Risk and Guam Gene-ius Terms and Conditions.

Signature: ______Date: ______

*Student Medical Information and Liability Release Statement by Science Discovery, University of Colorado Boulder

REGISTRATION AND CANCELLATION POLICY

Guam Gene-ius Program is filled on a first-come, first-served basis. Guam Gene-ius is limited to 23 students per session. It is recommended to register your child as soon as possible.The cost to register a child for the program is $70.00. Registration fees must be paid in advance to hold your place in the program. The cancellation policy is as follows:

Registration cancellation must be made no less than 3 days prior to the start of the first class of the program. A refund will be issued for the total registration fee paid. Cancellations made fewer than 3 days before the first day of class will not receive a refund.
Refund will not be processed for no-shows or if your child decides he or she does not want to continue with the program after the first day of class. No partial refunds will be issued for missed days of class.
If there is not an adequate number of applicants registered a minimum of 3 days prior to the start of the program, we reserve the right to cancel the session. Registration fees will be refunded in full in the event that the program is canceled completely.

Signature: ______Date: ______

MEDIA RELEASE

I authorize the College of Natural & Applied Sciences (CNAS), University of Guam, and those acting pursuant to its authority to:

(a)Record my/my child’s participation and appearance in:
Guam Gene-ius ProgramJanuary 13, 2018 to March 31, 2018
Name of EventDate
on videotape or audiotape, in photographs, or in any other recorded medium. I understand that these recordings may be used in any medium, including print, Web (website, Facebook, Twitter, and similar), video, or audio.

(b)Use my name, likeness, voice, and biographical material in connection with recordings.

(c)Exhibit or distribute such recording in whole or part without restrictions or limitations for any educational or promotional purpose, which CNAS and those pursuant to its authority, deem appropriate. CNAS will not pay, nor receive, remuneration for the use of images or recordings.

I waive any right I might have to inspect and/or approve the finished medium, or the use to which it may be applied.

I represent that I am at least 18 years of age and that I have read and fully understood the above paragraph and am knowingly and voluntarily executing this release without compensation to myself.

______
Signature

______
Name

______
Street AddressCityState/Island/CountryZIP

______
TelephoneE-mail

______
Parent/Guardian Signature (If under 18)