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Zoom into Careers Online Registration Form

Thank you for registering for Zoom into Careers! Zoom online registration form and payment will secure your enrollment on a first come first serve basis. Signed consent form must be received on or before the first workshop day. For questions, please call us at 1.800.256.2771 or email us at: zoom@selu.edu.

Fields marked with an * are required.

PARTICIPANT INFORMATION:

- Participant First Name:*
- Participant Last Name:*
- School attending in Fall 2013: *
- Grade entering in Fall 2013: *
- Date of Birth: *
- Gender:*This field is required.
  - Male
  - Female
- Parent/Guardian Name: *
- Street Address: *
- City: *
- State: *
- Zip Code: *
- Primary Phone# (include area code) *
- Alternate Phone# (include area code) *
- Primary Email Address: *
- Alternate Email Address:
- Yes, please sign me up for E-News!
- Check this box if the student will be driving him or herself to Zoom:
- Primary Emergency Contact Person, Authorized to Pick Up Child: *
- Relationship of Primary Emergency Contact Person to Child: *
- Primary Phone Number of Primary Emergency Contact Person: *
- Alternate Phone Number of Primary Emergency Contact Person:
- Secondary Emergency Contact Person, Authorized to Pick Up Child:
- Relationship of Secondary Emergency Contact Person to Child:
- Primary Phone Number of Secondary Emergency Contact Person:
- Alternate Phone Number of Secondary Emergency Contact Person:
- How did you hear about Zoom Into Careers?

PROGRAM INFORMATION:

- Pricing for all workshops:
- Early Registration (Through May 10) $280.00
- Regular Registration (May 11 - June 7) $295.00
- Late Registration (June 8 - June 13) $320.00
- *except where pricing differs below
- Please check program you would like to attend: *
  This field is required. Please select an option.
- Animation | June 17-20
- Industrial & Engineering Technology | June 17-20
- Kinesiology | June 17-20
- Television | June 17-20
- Welding | June 17-20
- Photography- Mandeville | June 17-20
- Automotive Technician- Walker- Registration fee $55 | June 17-20
- Criminal Justice - Walker - Registration fee $55 | June 17-20
- Web Design- Walker | June 17-20
- Automotive Technician- Greensburg | June 17-20
- Available only for high school students attending Hammond workshops: Animation, Industrial & Engineering Technology, Kinesiology, Radio, Television, Theatre, and Welding.
  
  Overnight Option - $150.00 includes room, meals, and evening activities. (High School Students Only)

PAYMENT INFORMATION:

- Credit Card Type: *
  This field is required. Please select an option.
- Master Card
- Visa
- Discover
- Other
- Other Credit Card:
- Name on Credit Card: *
- Credit Card Number: *
- Expiration Date: *
- Three Digit code on back of card: *
- Total amount to charge on my credit card: *
- Yes, please process my payment! *

CONSENT AND RELEASE:

WAIVER

In consideration of my child participating in Southeastern Louisiana University's Zoom into Careers Workshop(s), and on behalf of myself, my heirs, legatees, personal representatives, and all those claiming by or through me, I consent to, and so hereby discharge and release and forever hold harmless Southeastern Louisiana University and their affiliates, sponsors, agents, servants, employees, assigns, successors, and heirs and any facility at which events are held, from any and all claims, actions,losses, damages, or expenses for personal or bodily injury (including death) and property loss or damage of whatever nature or cause, incurred by me (or my child) arising out of or in any conjunction with my (or my child's) participation in the aforementioned activity. I hereby consent I am of legal age and capacity, and have read and understand the contents of the Consent and Release.

FIELD TRIP(S) | PHOTOGRAPHS

I hereby give full permission for the Participant to participate in and be transported to any field trip activity and to be photographed.

EMERGENCY HOSPITAL PERMISSION

I hereby give full permission to any adult at Southeastern Louisiana University to arrange for emergency care and transportation to the nearest hospital in the event of an emergency. In the event that emergency response is unavailable, I give my permission to any adult at Southeastern Louisiana to drive participant to the nearest hospital or urgent care facility.

Yes, I have read and accept the contents of the Consent and Release above.*

POLICIES:

ENROLLMENT

Complete registration form and related paper work. Enrollment will be processed on first come, first serve basis. Unless notified otherwise, applicants are to assume that they are enrolled in the requested workshop. Please return Registration form, Consent and Release form by deadline. Participant must be in good standing with current high school.

REFUNDS | CANCELLATION

A refund of 75% is given if a request (in writing) reaches the Continuing Education office one week prior to the first workshop date. Requests submitted after this time will receive a prorata refund. No refunds will be given after the first day of workshop. The University reserves the right to cancel any workshop due to insufficient enrollment. A full refund will be made to those students in a cancelled class. Southeastern Louisiana University reserves the right to dismiss a participant for just cause, such as misbehavior or disruption of activites. No refund will be given for dismissal.

SEVERE WEATHER

In the event of severe weather, please listen to local radio and television for updates on class cancellations. You may also contact us at 800.256.2771.

NOTE

If you are a qualified student with a disability seeking accommodations under the Americans with Disabilities Act, you are required to self-identify with the Office of Disability Services, Room 203, Student Union. Accommodations will not be granted without documentation from the Office of Disability Services. 985.549.2247. By signing this Registration Form, I understand the policy listed above.

Yes, I have read and accept the policy and information above.*

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