2016 NASIMCO Youth Leadership Retreat: Registration Form
Making Your Voice Count: Thinking Outside The Box

The NASIMCO Youth Leadership retreat is an annual program organized to empower youth to explore and develop leadership opportunities. The retreat combines facilitated workshops, debates, dialogue and recreational activities in order to optimize learning opportunities for all participants. The retreat will be held at the during Labor Day weekend, from September 2nd to September 5th, 2016 Warren W. Willis United Methodist Camp located on the scenic shores of Lake Griffin an hour northeast of Orlando, Florida. The goals of the retreat are as follows:

• To enable participants to explore assumptions, beliefs, and attitudes about themselves, and the environments in which they operate

• To develop the capacity for social and political leadership amongst the youth

• To facilitate the spiritual and social upliftment of youth in North America

• To enable the youth to realize their full potential
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2016 Retreat Information
When: Fri. Sept. 2nd (Morning) - Mon. Sept 5th (Afternoon)
(Labor Day Long Weekend)

Who: Ages 18 to 25

Where: Warren W. Willis United Methodist Camp in Fruitland Park, FL (one hour northeast from Orlando, FL)

Cost: $200 per person

Transportation: Bus service to & from The Husseini Islamic Center (Shia Ithna-Asheri Jamaat) of Orlando, Florida to the Warren W. Willis United Methodist Camp will be provided at no extra cost.

**Space is limited, register now!**

Note: Applicants are asked not to book their flights until your spot at the retreat is confirmed. If there are any questions please contact us at retreat@nasimco.org. Thank you!
Registration Form
Name *
Sex *
Age *
Email *
Phone Number *
Address *
Occupation *
Are you currently in school (college/university)? *
Required
If attending/attended school, what program or major do/did you study? *
If not applicable, please type "N/A"
What community do you affiliate with or belong too? *
T-shirt Size *
Receive a complimentary retreat t-shirt. If you have any additional needs, please indicate them in "other" and we will try to accomodate you.
Emergency Contact Name *
Relationship to you: *
Emergency Number *
Dietary Requirements
Clear selection
Disability Accommodations:
The NASIMCO Retreat Team actively encourages applications from youth with disabilities.

Should you require an accommodation in order to participate in this retreat, please email us at retreat@nasimco.org 

Additional Information
In a maximum of 250 words, please thoroughly answer the following questions in support of your application:
What are you passionate about? *
What activities, initiatives or programs are you currently involved in outside of work or school? If you are not involved, then what would you like to be involved in? *
What does “Thinking Outside the Box” mean to you? *
Why are you applying to attend the 2016 Retreat? What do you expect to get out of the 2016 Retreat? *
In your view, what are the current issues, needs, pressures or roadblocks facing the youth of your community/society? *
Do you feel the youth have a voice or are actively involved in your community? If yes, please provide examples of the programs or events they are involved in. If no, why do you think they are not involved? *
What possible community needs or problems, challenges, or issues can you identify that you care about? *
At the end of this retreat, will you make time to apply your knowledge and work on projects that will benefit your community? If yes, please explain how you would plan to do so. *
Waiver
I take full responsibility in participating in the activities made available at this camp.

Permission is granted for me to receive emergency medical treatment if needed the cost of which will be paid by me.  I hereby release and discharge NASIMCO, its officers, all its affiliated entities, volunteers, organizers, chaperones and representatives from any and all liability, claims, demands, damages, costs, expenses, personal injuries, and/or loss suffered by me in connection with my participation in the camp.

I agree that the grant and release contained therein binds me to all of its terms.

I understand and agree to the waiver outlined above.

Participant Name: *
Date: *
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