Escape Room Consent Form
Name
*
First Name
Last Name
Email
*
example@example.com- prefer not school email
Cell Phone
*
Please enter a valid phone number- texting is needed.
Format: (000) 000-0000.
School that you attend:
*
Grade that you are currently in:
*
Student's Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Student Citizenship Status
*
Please Select
US Citizen
Permanent Resident
I'd like to discuss
I need most help with
*
Please Select
Tutoring
Career Exploration
Financial Literacy
College Planning
Time Management
I want to go on this trip because:
*
I like the idea of learning more about teamwork and communication
I like the idea of experiencing new things and meeting new people
I like escape rooms
I just like Field Trips
Other
I am interested in this career:
*
Student Signature: I have read, understand, and agree to the informed consent and assumption of risk form.
*
Parent/Guardian Name
*
First Name
Last Name
Please list any allergies (food/bees,etc)
Parent or Guardian Phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent Email Address
*
example@example.com
Parent 1 Highest Education Completed
*
Please Select
Middle School
High School/ GED
Associate Degree (2 year)
Bachelor Degree (4 year)
Certificate
Graduate Degree
Educated outside the US
Unknown
Parent 2 Highest Education Completed
*
Please Select
Middle School
High School/ GED
Associate Degree (2 year)
Bachelor Degree (4 year)
Certificate
Graduate Degree
Educated outside the US
Unknown
Household taxable income
*
Please Select
1: 0-$21,870
2: $21,871 - $29,580
3: $29,581 - $37,290
4: $37,291 - $45,000
5: $45,001 - $52,710
6: $52,711 - $60,420
7: $60,421 - $68,130
8: $68,131 - $75,840
9: families more than 9 add $7,710
Household income is:
*
Please Select
Above the family size amount
Below the family size amount
Unsure- I'd like help to figure it out
This in reference to the household taxable income in the question above.
Parent Permission and Signature: My signature indicates that I have read, understood and agree to the attached 'Informed Consent and Assumption of Risk' form.
*
Submit
Should be Empty: