Registration Form for Event Coordinators

Fill out the following form to register to be a 2018 Utah Science Olympiad event coordinator:

Student Information Form

Name *

First and Last

Pronunciation (if not obvious)

School Name *

Date of Birth *

(format mm/dd/yyyy)

Gender *

Male

Female

Gender Neutral

Graduation Year * 2018 2019 2020 2021 2022 2023 2024 2025 2026

Mailing Address *

City *

Zip Code *

County * Beaver Box Elder Cache Carbon Daggett Davis Duchesne Emery Garfield Grand Iron Juab Kane Millard Morgan Piute Rich Salt Lake Sanpete Sevier Summit Tooele Uintah Utah Wasatch Washington Wayne Weber

Email *

Phone *

format (xxx) xxx-xxxx

Ethnic Origin *

Caucasian

Latina/o or Hispanic

American Indian or Native Alaskan

Black or African American

Asian American

Native Hawaiian or Pacific Islander

(choose all that apply)

Have you previously attended the State Science Olympiad tournament before? *

No

2017

2016

2015

2014

2013

2012

2011

2010

(Click all that apply)

Will you need any special accomodations during the competition? * Yes No

If yes, please list any and all accomodations you will need:

Please list any medical problems that you may have in the event you should need emergency medical care
(for example, allergic reactions, heart problems, etc.) *

Media Release: I have read and hereby consent to the terms of the Media Release as described here. *

Yes

Science Olympiad Code of Ethics:
I have read and hereby consent to the terms on the National Science Olympiad website as described here. *

Yes

Student Information: I have read and hereby consent to the terms of the release of Student Information
as described here. *

Yes

U of U Liability Form: I will download and complete the liability form and bring with me to state as found here. *

Yes

Student Signature *

Parent/Guardian Signature *