OSPI provides equal access to all programs and services without discrimination based on sex, race, creed, religion, color, national origin, age, honorably

discharged veteran or military status, sexual orientation, gender expression, gender identity, the presence of any sensory, mental, or physical disability, or the

use of a trained dog guide or service animal by a person with a disability. Questions and complaints of alleged discrimination should be directed to:

Equity and Civil Rights Director, P.O. Box 47200, Olympia, WA 98504-7200 | (360) 725-6162/TTY: (360) 664-3631

DARE TO DREAM ACADEMY ONLINE STUDENT REGISTRATION PACKET SCHOOL DISTRICT INFORMATION DISTRICT NAME:

DISTRICT CONTACT NAME:

DISTRICT CONTACT PHONE:

DISTRICT CONTACT EMAIL:

STUDENT REGISTRATION INFORMATION STUDENT’S NAME: GRADE LEVEL:

UNIVERSITY STUDENT IS ATTENDING: ❑ CWU ❑ EWU ❑ UW ❑ WSU-Spokane ❑ WSU-Pullman ❑ WWU

ACADEMY STRAND: ❑ Exploring Your Future ❑ Math Academic Academy ❑ Science Academic Academy ❑ Biology Academic Academy ❑ Health Sciences Academy

REGISTRATION PROCESS

STEP 1: PROCESS ONLINE REGISTRATION STEP 2: SUBMIT REGISTRATION PACKET Online registrations and standby requests are to be completed online through the MSIS Student Event database www.msdr.org

Registration Deadline: April 30, 2021 Please mail, fax, text, or email

the completed registration packet forms signed by parent/guardian and student to MSDRS.

CALL ............................................................ (509) 837-2712

EMAIL .......................................................... Events@msdr.org

TEXT ............................................................ (509) 439-2300

FAX ........................................................... (509) 839-9017

MAIL:

MSDRS-Student Support Services Attention: Dare to Dream Academies

810-B East Custer Avenue, Sunnyside, WA 98944 (Forms must be postmarked no later than April 30th)

REGISTRATION PACKET FORMS CHECKLIST

A listing of the forms along with required information.

❑ Student Academy Profile Questionnaire

❑ Online Assumption of Risk

❑ Online Code of Conduct

❑ Image and Voice Recording Consent (RESPONSE

REQUIRED) ❑ Online Registration Packet Consent Form

(SIGNATURE REQUIRED)

Remember to keep a copy for your files.

IMPORTANT All Dare to Dream Academy strands will be conducted through an online learning management system platform. Please make sure ALL forms are completed and signed. NOTE: The online registration database confirms the students’ ability to participate in an on-line platform. To complete the registration process, please login to the Student Event database and ensure all fields are completed and submit this completed packet to MSDRS. Ensure all information is completed and signatures for both parent/guardian and student (where applicable) are present before submitting the registration packet.

April 7, 2021

Dare to Dream Academy Online Registration Packet Page 1 of 7

STUDENT ACADEMY PROFILE QUESTIONNAIRE Tell us a little about yourself:

Student Name:

Student District Email: Student Personal Email: Academy staff will use student emails for academy related correspondence only, and the emails will not be shared for non-academic purposes. Students must be able to access email during the summer.

I Can Be Available to Participate in the Online Academies During: ❑ AM Only ❑ PM Only ❑ Either Only select academies will offer both an AM and PM strand. Please ensure the academy you are registering for offers a scheduled program time when you are available.

My T-shirt Size is: ❑ XS ❑ S ❑ M ❑ L ❑ XL ❑2XL ❑ 3XL T-shirts/Lab Coats are provided at the discretion of the individual sites and may not be provided for every academy.

Parent/Guardian Name 1: Phone:

Email: Relationship to Student:

Parent/Guardian Name 2: Phone:

Email: Relationship to Student:

One thing I wish academy staff and mentors knew about me is: My Preferred Pronouns Are: ❑ He/Him ❑ She/Hers ❑ They/Them ❑ Not Listed: My Preferred Language Is: ❑ English ❑ Spanish ❑ Other

With remote learning this past year: What is one thing I found challenging: What is one thing I enjoyed:

Do you have any needed learning accommodations?

*Dietary Restrictions and Allergies (Some universities may send food materials for students either for academy activities and/or snacks. Please share if there are any dietary restrictions below.):

Do you have any food allergies or dietary restrictions? ❑ Yes ❑ No If you answered yes, please explain:

Technology: Please complete the questions below:

1. Do you have a *laptop or computer accessible through summer either personal or with district support? ❑ Yes ❑ No

a. Does your device have a functional webcam? ❑ Yes ❑ No

b. Does your device have a functional microphone? ❑ Yes ❑ No

c. Do you have *Canvas (online learning platform application) installed on the laptop or computer? ❑ Yes ❑ No

d. Do you have * Zoom (online video meeting platform application) installed on the laptop or computer? ❑ Yes ❑ No

e. Do you have *Nearpod (online learning platform application) installed on the laptop or computer? ❑ Yes ❑ No

f. Do you have access to Google Classroom Suite applications on your laptop or computer? ❑ Yes ❑ No

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Dare to Dream Academy Online Registration Packet Page 2 of 7

STUDENT ACADEMY PROFILE QUESTIONNAIRE 2. Do you have *internet access or hotspot devices either through personal private connection or with district

support? ❑ Yes ❑ No

3. Do you have an *email address you can access for academy communication through summer? ❑ Yes ❑ No

Your district does not have to purchase a Canvas, Zoom, Google or Nearpod subscription.  The Canvas and Nearpod learning management system will either be offered by AWSP or the partner university.  Your local contact who is registering you should be able to work with your local IT Department to assist you with downloading the applications onto your device and/or ensure the website access will allow you to fully participate, interact and upload academy coursework.  *Please note:  Students attempting to take this course through a smart phone may have technology limitations.  It is better to have access to a laptop or computer.  In no way should a personal private connection or need for technology be a financial burden to the family. Please contact OSPI's Migrant Education Program, at Griselda.Guevara-Cruz@k12.wa.us if there is a need to support internet access or technology equipment needs.

IMPORTANT MAILING AND SHIPPING INFORMATION

The Migrant Education Program will provide the following to participants: • Water Bottle • Backpack • Pencil • Eraser • Pencil Sharpener • Academy Curriculum and Supplies, as needed

To ensure that the materials arrive at the correct address and in a timely manner, please provide the

following information:

FOR SHIPPING PACKAGES (UPS will not ship to PO Boxes):

Student Physical Address:

APT/TRLR/SP #: City: State: ZIP:

FOR MAILING LETTERS:

Student Mailing Address:

APT/TRLR/SP #: City: State: ZIP:

By completing the Student Academy Profile Questionnaire, we the student and parent/guardian, attest we have read, understand, and completed the form to the best of our ability. The student and parent/guardian commit to meet the program technology requirements through personal equipment and connection OR by con tacting OSPI’s Migrant Education Program for support at Griselda.Guevara-Cruz@k12.wa.us.

Dare to Dream Academy Online Registration Packet Page 3 of 7

ONLINE ASSUMPTION OF RISK

Central Washington University, Eastern Washington University, University of Washington, Washington State University Spokane and Pullman Campuses, Western Washington University (the University)

and Office of Superintendent of Public Instruction (OSPI) Dare to Dream Academies

ACTIVITIES

I understand that there are risks in participating in an online Dare to Dream Academy activities and educational workshops.

In consideration for and as a condition of being allowed to participate in this voluntary activity, I agree to take full responsibility for any and all risks that may exist including personal injury and/or death, psychological and/or emotional injury, and property damage or loss from any activity I may engage in while participating in the program. I expose myself to the risks of personal injury from engaging in these activities including but not limited to: eye strain or injury, carpal tunnel syndrome, arm, neck, back, and general bodily fatigue and injury, falls, stress, panic, anxiety, psychological and emotional distress and injury, physical and emotional pain and/or suffering, and/or death and/or property damage. I understand that there may be risks that the University/OSPI cannot predict or foresee, and I also assume full responsibility for those risks.

Because the Internet is an worldwide vehicle for communication, information available to academy staff and students is impossible to control. Risks in participating in the online Dare to Dream Academy activities (including use of the world wide web, an online learning management tool, video chats, use of online chat rooms, and/or synchronous and asynchronous exchange of online resources etc.), include, but are not limited to: exposure of personal information or personal data by unauthorized persons, identity theft, security risks and threats as a result of unauthorized hacking and viruses and which may expose users to, among other things, inappropriate and/or illegal content and images. I also recognize that there are both foreseeable and unforeseeable risks of that may occur as a result of participating in an online Dare to Dream Academy program that cannot be specifically listed. Further, I recognize that the actions of other students in the activity may cause harm to my child.

RELEASE OF LIABILITY I release, the state of Washington, the Office of Superintendent of Public Instruction (OSPI), the Regents and/or Board of Trustees of the Washington State University (“University”), any subdivision or unit of the University its officers, employees, and agents, from any and all liability, claims, costs, expenses, injuries and/or losses to person or property as a result of or connected with my child’s participation in the above event. My child’s participation includes, but is not limited to, any activity connected with the event itself including use of the world wide web and/or other offline electronic platforms. I have carefully read this document, understand its contents, and am fully informed about this program and circumstances. I am aware that this document is a contract with the University/OSPI and the program sponsors. I enter into this contract by signing the Online Registration Packet Consent form freely and voluntarily.

Dare to Dream Academy Online Registration Packet Page 4 of 7

ONLINE CODE OF CONDUCT

The Dare to Dream Academies strives to offer a safe and wholesome environment in which students virtually participate and learn as part of a greater community. Student attitude and behavior are critical to the success of the Academy community and each individual makes a difference in the quality of the camp experience.

In order to create an inclusive and respectful community atmosphere, students agree to follow these behavioral guidelines during their Academy. Students and parents/guardians must read and sign this agreement prior to academy attendance. Student Pledge:

• I will always treat everyone in the academy community with respect, including showing respect for another’s privacy and feelings.

• I will exercise good judgement.

• I will exhibit exemplary behavior on the network as a representative of my school and community. Be polite!

• I understand that harassment and other forms of discrimination based upon race, color, religion, creed, sex, national origin, age, sexual orientation, gender expression, or disability violate federal and/or state law and University policy, and they will not be tolerated.

• I will not use obscene or foul language or gestures or make reference to violent offensive actions.

• I will not engage in any activity which may put me, other students, or staff at risk.

• I will dress according to my school’s dress code policy when participating in virtual conference or posting pictures to group chats, etc.

• I will observe the virtual classroom hours that have been established.

• I agree to abide by the rules and regulations of the camp and understand that I am expected to follow directions and guidance provided by the Academy staff.

• I will set goals to do daily studying that facilitates Academy completion and long-term goals. This daily routine could include reading, studying, journaling, and/or completing other Academy activities.

• I will return all assignments completed to the best of my ability and on time.

• I will take extreme caution to NOT share my personal information or that of another Academy participant or reveal items of personal nature when online.

• I will safeguard my login username and password and only use the account for the authorized purpose.

• I will NOT use the Academy online learning management platforms to engage in illegal, harassing, vandalizing, inappropriate or indecent activities online.

• I will NOT use technology to interfere or disrupt other Academy participants, services or equipment, including distribution of unsolicited advertising (SPAM), propagation of viruses and distribution of large quantities of information (chain letters, network games, or broadcasting messages).

• I will respect copyrights and cite sources appropriately, and not present someone else’s work as my own.

(Continued on the next page)

Dare to Dream Academy Online Registration Packet Page 5 of 7

ONLINE CODE OF CONDUCT Parent Pledge:

• I will support my child in creating a daily routine that includes Academy activities, reading or Academy study time in a quiet location.

• I will check with my child daily regarding Academy activities.

• I will make sure my child gets an adequate night’s sleep.

• I will have my child participate every day of the Academy for the hours that have been established.

If the student fails to abide by these behavioral expectations the parent/guardian will be notified by phone and the student will be removed from the Academy.

The following behaviors will result in immediate expulsion from the Academy and potentially may constitute criminal misconduct requiring a report to law enforcement:

• Any crime, including identity theft, online harassment, propagation of virus, hacking other user accounts or any other illegal product. If student learns of any illegal activity conducted by another user or suspects malicious activity, the student must immediately report it to the Academy staff or it may be considered in violation of the code of conduct.

• Failure to follow staff instructions thereby resulting in situations that put themselves, other students, or staff in physical or virtual danger.

• Verbal abuse of another student and/or staff member.

• Students threatening to harm themselves or other students or engaging in actions reasonably likely to result in harm to themselves or others.

By signing the Online Registration Packet Consent Form, we the student and parent/guardian, agree we have read and understand the behavioral expectations, including provisions for immediate expulsion as stated in this document.

• Student only: I agree to abide by the behavioral expectations at all times while participating in the on-line Dare to Dream Academy activities.

• Parent/Guardian only: I agree that I have discussed these expectations with my student, who has agreed to abide by the behavioral expectations at all times while participating in the online Dare to Dream Academy activities.

Dare to Dream Academy Online Registration Packet Page 6 of 7

ONLINE IMAGE & VOICE RECORDING CONSENT

YES, We, the parent/guardian and student, hereby grant permission to the University and the

Office of Superintendent of Public Instruction (OSPI) to be photographed or otherwise have images or voice recordings made (including but not limited to digital photographs, video or digital moving images and/or voice recordings), for University/OSPI publication or promotional purposes in any medium (including but not limited to print media, newspaper, television, video, motion picture, or Web site on the Internet).

Some of the online classes may be recorded and posted on the instruction platform for use by students and instructors in the class. These recordings of the synchronous sessions would allow for review of material covered in class and/or could be used by those who were unable to participate in the synchronous class online. I also authorize and consent to the Academy and University to make audio recordings that may identify my child’s name, voice and/or statements for educational and learning purpose related to the Academy.

We additionally consent to the use of student’s name and/or interview comments in connection with University/ OSPI publication or promotional purposes in print media, newspaper, television, video, motion picture, or website on the Internet.

We understand that consent to use of student’s likeness or voice recordings is not a condition of participating in the activity and that consent can be refused without any impact in the ability to fully participate in the program.

No inducements or promises beyond our acceptance of an opportunity to promote University/OSPI and its programs have been given to the persons signing below.

Any other use of images and/or recordings, student’s name, and/or interview comments requires advance permission.

We understand that we can revoke this consent at any time upon notice to University/OSPI, at which time either or both of us will sign a copy of the denial (below) for use of images or voice recordings.

No, We, the parent/guardian and student, do not agree to the use of digital images or voice

recordings as set forth above.

By signing the Online Registration Packet Consent Form, we, the parent/guardian and student, agree we have carefully read the form, understand the content, and selected to consent or decline consent freely and voluntarily related to the use the student’s image and voice recording.

Dare to Dream Academy Online Registration Packet Page 7 of 7

REGISTRATION PACKET ONLINE CONSENT FORM BEFORE SIGNING, PLEASE READ: An original signature is REQUIRED for all WSU Academic and Health Sciences Academies. An electronic signature will be accepted for all other university academies.

By signing below, I agree that I have carefully read each of the components contained in this registration packet, understand the content and significance, I am fully informed about this program, the circumstances and activities and agree to each of the terms outlined in the components of this registration packet.

❑ Student Academy Profile Questionnaire: By completing the Student Academy Profile Questionnaire, we the student and parent/guardian, attest we have read, understand and completed the form to the best of our ability. The student and parent/guardian commit to meet the program technology requirements through personal equipment and connection OR by contacting OSPI’s Migrant Education Program for support at Griselda.Guevara-Cruz@k12.wa.us.

❑ Online Assumption of Risk Form: As the parent/guardian, by signing below, I agree I have carefully read the document, understand its contents and am fully informed about this program and circumstances. I am aware that the document is a contract with the University/OSPI and the program sponsors. I enter into this contract freely and voluntarily.

❑ Online Code of Conduct Form: By signing below, we the student and parent/guardian, agree we have read and understand the behavioral expectations, including provisions for immediate expulsion as stated in this document.

• Student only: I agree to abide by the behavioral expectations at all times while participating in the online Dare to Dream Academy activities.

• Parent/Guardian only: I agree that I have discussed these expectations with my student, who has agreed to abide by the behavioral expectations at all times while participating in the online Dare to Dream Academy activities.

❑ Online Image and Voice Recording Consent Form: By signing below, we, the parent/guardian and student, agree we have carefully read the form, understand the content, and selected to consent or decline consent freely and voluntarily related to the use of the student’s image and voice recording.

PARENT/GUARDIAN: I voluntarily sign this authorization in consideration for permission for my child to participate in the Dare to Dream Academy.

Signature of Parent/Guardian (for student less than 18 years of age):

X Date:

Electronic Signature: I have reviewed the form and certify that it is correct and accurate. I agree with all the terms and conditions of the form. I agree that my typed signature above will be considered an original signature on the form.

Relationship to Student:

STUDENT: I voluntarily sign this authorization for consideration of my participation in the Academy.

Signature of Student:

X Date:

Electronic Signature: I have reviewed the form and certify that it is correct and accurate. I agree with all the terms and conditions of the form. I agree that my typed signature above will be considered an original signature on the form.