Mote Marine Laboratory & Aquarium
Summer High School Volunteer Program
Print the following information:
Name __________________________________ Birthday ___/___/___ Gender ___ Grade ___
Parent/Guardian Name(s) ___________________________________________________________
Street _________________________________________ City _______________ Zip Code _______
High School _______________________________ County _________________
Street ________________________________________ City ________________ Zip Code ______
School Website ________________________________ Telephone (____) ____________________
Counselor Name _______________________________________
Are you volunteering to secure hours for a school requirement? YES _____ NO ___
If yes, will the hours be used for “Bright Futures Scholarship”? YES _____ NO ___
How many hours will you volunteer at Mote in order to fulfill your requirement? _____
I understand I am applying to be considered for admission into Mote’s Summer High School
Volunteer Program. If selected, I will follow the program guidelines and complete all requirements
including training and shift assignments as required for the program. I agree to log my volunteer
hours into the student log book and submit them to my school for credit. I also understand that this is
a commitment of responsibility, time, energy, and enthusiasm and will try to uphold these to the best
of my ability.
Signature of Applicant _______________________________________________ Date _________
I support my child in their application for Mote’s High School Volunteer Program. I also support my
child, if applicable, in driving my child to and from meetings and volunteer opportunities.
Signature of Parent/Guardian _________________________________________ Date _________
Comments or Questions:
MOTE MARINE LABORATORY & AQUARIUM
EMERGENCY MEDICAL TREATMENT
AUTHORIZATION & VIDEO RELEASE FORM
Student’s Name ________________________________________ Date of Birth ___/___/___
Parent/Guardian Name(s) _______________________________________________________
Program Title Summer High School Volunteer Program Date of Program Summer of 2012
Student’s Address _________________________________ City ______________ Zip Code______
Age ____ Gender ____ Home Phone # (____)___________ Business Phone # (____)____________
Health/Accident Policy Co. (Name & Address) ___________________________________________
_________________________________________ Policy # ________________________________
Emergency Contact _____________________________ Emergency Phone # (____) ____________
Please list ANY physical limitations, medical problems, and special dietary/medical needs (use reverse side, if
**Please attach a photocopy of the insurance card to this form**
RELEASE AND WAIVER OF LIABILITY: I give permission for Mote Marine Laboratory staff to provide any medical
assistance they feel appropriate for my child named above. I also give permission for any emergency personnel to treat
my child in the event of an emergency. I will be responsible for any and all medical expenses that may be incurred. In
consideration of the right to participate in the Mote Marine Laboratory Volunteer Program, I, for my self and my minor
child, have and do hereby assume all risks and will indemnify and hold harmless Mote Marine Laboratory, its employees,
trustees, officers, volunteers, and members from any and all liability, actions, causes of action, debts, claims, demands or
other liability of every kind and nature whatsoever which may arise from or in connection with my child’s participation in
any activities sponsored through MML, whether caused by ordinary negligence or otherwise. This signed agreement will
serve as a release or assumption of risks for my heirs, executor and administrators, assigns, or next of kin and for
members of my family. If any portion of this release is found invalid, the balance will remain in full legal force and effect.
The undersigned hereby authorizes Mote Marine Laboratory personnel to: photograph, film, audiotape, interview and/or
take recordings of any kind on any media of the participant listed above during any Mote program, event or visit to Mote
Aquarium; to take, publish or use the name listed above or any picture, recording or copy of my/our image, likeness or
voice. Permission includes the right to retouch, edit and make such alterations to photographs, video, web or audio
recordings that Mote Marine Laboratory & Aquarium may desire; full unreserved rights to use the photographs, videotape
recording and audio recording taken for purposes of display, reproduction, broadcast and/or publishing, in any medium of
public or private communication as to promote or inform the public about any programs at Mote Marine Laboratory &
Aquarium, a nonprofit organization; to publish or reprint information provided by the participant(s) listed above on their
experiences at Mote Marine Laboratory and Mote Aquarium, including any and all programs run by personnel, volunteers,
their successors and assigns, in any and all media, including print and Internet publications; and all rights, royalties and
materials will belong to Mote Marine Laboratory & Aquarium and no compensation will be provided.
PLEASE CHECK ONE.
□ I, the undersigned, hereby release and discharge Mote Marine Laboratory from any and all claims and
demands arising out of or in conjunction with the use of visual and audio recordings, OR
□ I, the undersigned, do not agree with the above and do not want my minor child to be photographed, filmed,
and/or interviewed for the above purposes.
Parent/Guardian: You must sign the completed form in front of a Notary Public. Your minor
child will not be able to participate unless your signature is witnessed by a Notary Public. Thank you.
NOTARIZED SIGNATURE and PRINTED NAME OF PARENT/LEGAL GUARDIAN
Signature _______________________ Printed Name________________________ Date ________
STATE OF _______________________ COUNTY OF ____________________________
The forgoing instrument was acknowledge before me this ____ day of _________________, 2012,
by, ______________________________ who is personally known to me or who has produced
_________________________________ as identification who (did) (did not) take an oath.
NOTARY PUBLIC SIGNATURE EXPIRATION
NOTARY PUBLIC PRINTED/TYPED NAME
Mote Marine Laboratory & Aquarium
Summer High School Volunteer Program
Please use the space provided to answer the following question:
(Question must be answered by applicant only.)
As a Summer High School Volunteer Program participant, you will be volunteering in the Aquarium
interacting with our guests and talking about our exhibits. Why are you interested in participating in
Application Checklist 2012
Applications are not considered complete unless all of the following items are included.
Submit all items in one large envelope to Mote.
1. Completed Application Form
2. Notarized medical/press release form
3. Short answer question.
Mail or drop-off the completed application to:
Mote Marine Laboratory
1600 Ken Thompson Parkway
Sarasota, FL 34236
Applications are due by 5:00 p.m., Friday, April 6, 2012
Applications will be accepted by mail or drop-off only (NO FAXES).
Late or incomplete applications will not be considered. Call 941.388.4441, ext. 438 with any