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University of Iowa School of Journalism and Mass Communication - Iowa Summer Journalism Workshops

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First Name

Last Name

Date of Birth

Address

City

State

Zip

Personal Information

Name for badge

Student email address

Student cell phone during camp

County of residence

Date of Birth

Student’s age (as of July 13, 2025)

Year/class in school this coming fall

High School graduation year

Name of school currently attending

Media advisor name (if applicable)

T-shirt size

Student Sex (need for housing assignments only)

Roommate Request

First and last name of roommate (no nicknames please)

Parent Information

Parent/Guardian name

Parent/Guardian email

Parent/Guardian primary phone

Arrival and Departure Information

Arrival Time: Will your student arrive at check-in time or will they need special early/late arrival arrangements?

Departure Details: Who will pick up your student (if applicable)? Please include any early/late departure details.

Mode of transportation to be used

Will student require transportation from the Cedar Rapids (CID) airport or Iowa City Trailways bus station? Please provide available details.

Health Information

Health Insurance company

Policy holder’s name

Policy holder’s phone

Insurance company address

Policy number

Group number

Other health or accident coverage (Medicare, etc.)

General Information

How did you hear about the Iowa Summer Journalism Workshops?

Previously attended camp (if yes, number of times)

Waiver

In consideration for my child being permitted to participate in The University of Iowa Summer Journalism Workshops, on behalf of my child, our family, our heirs, and assigns, I hereby release and hold harmless The University of Iowa; Board of Regents, State of Iowa; the State of Iowa; the Iowa Summer Journalism Workshops, and each of their respective employees, agents and representatives (Releasees) from any and all liability for personal injury, including death, or property damage or loss suffered by my child as a result of, arising out of, or in any way involving participation in the summer workshops, including while traveling to/from the workshop activities for field trips associated with my child’s workshop course, except to the extent that such liability results directly from the negligence of the University of Iowa, its agents, or employees.

I acknowledge that I know, understand, and appreciate the inherent risks in participating in the Iowa Summer Journalism Workshops and field trips. These risks may include, but are not limited to: mechanical breakdown; vehicular accident; paralysis, concussion, or other bodily injuries, or death; and damage to or loss of personal property. The risks include exacerbation of pre-existing medical conditions. By signing this agreement, I fully assume the inherent risks associated with the workshops and associated activities and assert that my child is voluntarily participating in the activities.

Media Release

I grant the University of Iowa and persons acting for or through them the right to use, reproduce, assign, and/or distribute images, audio and video recordings, and likenesses in any medium whatsoever, for any minor children, identified below, for whom I have custody, for the purpose of promoting the University of Iowa, any of its programs or Centers, or for any other lawful purpose, without payment to me. The University, its successors and assigns shall own all right, title and interest, including the copyright, to any such image, recording, or likeness.

I hereby release and hold harmless the Board of Regents, State of Iowa; the University of Iowa; the Iowa Summer Journalism Workshops; and the State of Iowa, as well as each of their respective agents and employees from any and all claims, including but not limited to claims of infringement, damages or remuneration, for invasion of privacy, defamation, or misappropriation, or otherwise arising from such use.

Medical Release

In the event my child requires medical care while attending the Program, all reasonable attempts will be made to contact me at the phone numbers provided to obtain consent for treatment. In the event you are unable to reach me, emergency treatment may be provided as needed. If in the judgement of the heath care provider the medical care is not an emergency, no treatment will be provided until my consent has been provided by phone or in person.

I agree to assume all costs related to such treatment and authorize my insurance company to pay benefits to the University of Iowa Student Health Service, the University of Iowa Hospitals and Clinics, or UI QuickCare. Also, I authorize the disclosure of medical information to my insurance company for the purposes of this claim. (Each camper must provide his/her own health insurance.)

Signature

Date Signed

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