Verizon Innovative Learning NOTE: This form is for Verizon Innovative Learning Academic Year Registration only. Participant Name: * First: First: Last: Last: School Name: * Grade: * - Select -6789 Age: * - Select -10111213141516 Free or Reduced Lunch: * Yes No Gender: - Program is for Males Only* * Male Female Race/Ethnicity: * African American/Black Caucasian/White Native American Asian Pacific Islander Hispanic/Latino Other List all physical and /or dietary restrictions and any known allergies: * Parent/Guardian: * Relationship: * - Select -MotherFatherGuardian Home Number: * Cell Number: * Add Additional Parent/Guardian NoYes Relationship: - None -MotherFatherGuardian Home Number: Cell Number: Mailing Address: Country - None -United States Address 1 * Address 2 City * State * - Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming--Armed Forces (Americas)Armed Forces (Europe, Canada, Middle East, Africa)Armed Forces (Pacific)American SamoaFederated States of MicronesiaGuamMarshall IslandsNorthern Mariana IslandsPalauPuerto RicoVirgin Islands ZIP code * Parent's Email Emergency Contact Person: First: First: Last: Last: Phone Number: Person(s) NOT allowed to pick up child: Please supply our office with a list of no more than four names of people allowed to pick up your child. No one under 16 of age will be allowed to pick up a child. Photo ID will be required for anyone other than parents when picking up children. Person MUST be listed here in order to pick up child. Personal Information Sharing: * By typing your NAME and RELATION TO THE APPLICANT below, you indicate that you understand that if selected as a VIL Scholar, I will participate in and will be provided support (program materials, meals, etc.) for three weeks and on Saturday's during the academic year. By clicking "Submit Application," I authorize Delaware State University to share the personal and educational data provided using this online form, in addition to any supplemental information provided. The information will only be shared with potential faculty mentors and relevant staff. This consent applies to education data that may otherwise be protected under the federal Family Educational Rights and Privacy Act of 1974, as amended, 20 U.S.C. 1232g, also known as FERPA or the Buckley Amendment. This authorization will remain in effect until rescinded in writing. Without permission to share the application data, we cannot process the application.. If you have any questions, contact us at firstname.lastname@example.org. Verizon Innovative Learning participants will not engage in any serious actions which put the participant, other participants, staff or faculty’s safety in jeopardy, such as: inflicting physical or emotional harm on self or others, vandalism or destruction of DSU property or equipment; theft of DSU property or the property of another participant; consistently disrupting the course and impeding the learning of other participants, INCLUDING use of cell phones, iPads, and other electronic devices. We have read and understand the Conduct Expectations for the Verizon Innovative Learning Program at Delaware State University and Capital/Red Clay School District middle schools. We further understand that failure by the student to abide by the program expectations or to respect the authority of program staff may result in sanctions including: limitations on activities, restitution for property or equipment damage, or expulsion from the program.