2019 Youth Interactive Safety Lab Registration Form Are you a member of NOYS?*Yes, I am affiliated with a NOYS member.Not yet, but please contact me about membership benefits!I am a government agency employeeI am an educator or advisorI am a parentI am a studentName* First Last TitleOrganization Name* Organization Name Organization Address* Street Address Address Line 2 City State ZIP / Postal Code Email* Phone*Student Attendees - How many students will you be bringing?NOYS requires signed consent forms from all Lab participants and guests under the age of 18 must bring a completed form, signed by their parent or legal guardian with them to the Lab. The required form will be sent with your registration confirmation. Contact April Rai for more information: firstname.lastname@example.org. Number of Student AttendeesRegistration FeeNOYS Member Lab Registration Fee Price: $50.00 Quantity: Not A Member Lab Registration Fee Price: $100.00 Quantity: Government Organization Lab Registration Fee Price: $0.00 Quantity: School Lab Registration Price: $0.00 Quantity: Suggested Donation of $1 Per Student Price: $1.00 Quantity: Total $0.00 Lab Liability Agreement* Interactive lab participants must sign liability waivers to participate in the day's activities. Guests under 18 years of age must bring a waiver signed by a parent or legal guardian. A link to the waiver form will be sent in your confirmation email. Please click here to acknowledge your acceptance and commitment to signing a waiver form before participating in the Lab. Photo/Video Consent* I hereby grant to NOYS and its representatives the right to photograph, videotape, or otherwise digitally collect my likeness, name, voice and sounds (as “Works”) and assign and grant all rights in these Works to NOYS. This gives NOYS the right to use or sublicense these Works and use my name, likeness and biography without compensation or prior inspection and without any claim of defamation, invasion of privacy, violation of my right of publicity, copyright infringement, or any claim of video or audio alteration or faulty mechanical production, in NOYS’s discretion, in all media, for the promotion of NOYS and its mission and program. Billing Address (if different from above) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Expiration Date Security Code Cardholder Name Thank You!Thank you for registering to be a part of the 2019 Youth Interactive Safety Lab on October 21, 2019. We are looking forward to a great event!