NEBRASKA ACADEMIC DECATHLON

STUDENT REGISTRATION FORM

I, (PLEASE PRINT OR TYPE) ______

First Middle Last

now a student at ______High School in

Grade ____ and living at ______

Number Street Apt. #

( )

CITYZIP TELEPHONE # SOCIAL SECURITY #

Name(s) of parent(s)/guardian(s): ______

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 appli-

cable). 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 “the 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 indem-

nify the Grantees from and against any and all liability arising out of the exer-

cise of the rights granted by this release.

______

Signature of Student

______

Signature of Parent/Guardian 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. 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.

Finally, the Social Security number is needed to process any scholarships earned from participation in the decathlon. All regular team members of the 1st, 2nd, and

3rd 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 recipi-

ent 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 scholar-

ship. 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.