C2 Pipeline Registration Form 2023-2024

Fields with asterisks (*) are required.

Student Attended the Program Last Year *
Race (Check all that apply) *

Parent Information

Primary Parent or Guardian Information - Primary Emergency Contact

Lives with student *
Authorized to pick up student *

Medical History/Information

Waiver and Authorization

I hereby give permission for the above student to take part in the Wayne State University C2 Pipeline ("Program") activities, which may include off-campus events, academic assistance, college/career and group counseling, continuing education, recreational programming. If a medical emergency arises, I understand Program staff will secure emergency medical and or emergency surgical treatment for my enrolled child. I understand that I will be responsible for any emergency transportation charges and medical expenses incurred.

I voluntarily give my consent to Wayne State University and those acting to their authority on behalf of the Wayne State University C2 Pipeline Program to record my child's participation and appearance on video tape, audio tape, film, photograph or any other medium during program activities. Any recording/photo or tape may be used by Wayne State University for education and public relations purposes which may include social media or public access websites. I further give my consent for my child's school to share the student's academic records with the Wayne State University C2 Pipeline Program for purposes of providing educational support and assistance. In addition, I understand that Wayne State University will use participant records only to evaluate my child's individual progress and improvement, as well as to evaluate the impact of the program on my child's achievement and to obtain continued funding for the program.

I hereby certify that I have read and do understand the above information, the program rules, and I agree to them.

I acknowledge and agree to the above disclaimer of liability *