NNUY Leadership Program Application

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Student Name ( First, Last) *

Cell Phone Number (xxx-xxx-xxxx) *

Email Address *

Address *

City, State, Zip *

Mother's Name *

Mother's Phone Number *

Father's Name *

Father's Phone Number *

Additional Information

I have read the benefits and expectations of the Network New Ulm Youth Leadership Program and would like to be considered for participation. Participation fee is $50 due upon acceptance. Upon acceptance I will be required to have parents signature indicating they agree with my participation in the program. In addition, I will be expected to participate in a group service project as part of my commitment to the program.

I may need a scholarship in order to participate in the program *

Yes

Liability Release

In consideration of NNUY allowing the Participant to participate in the NNUY program, I, the undersigned, do hereby release, forever discharge and agree to hold harmless NNUY, its volunteers and agents from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the Participant while involved in the children/youth activities. I the parent or legal guardian of this Participant hereby grant my permission for the Participant to participate fully in NNUY activities. Furthermore, I, on behalf of my minor Participant, hereby assume all risk of accidental personal injury, sickness, death, damage and expense as a result of
participation in NNUY activities. The undersigned further hereby agrees to hold harmless and indemnify NNUY for any liability sustained by said NNUY as the result of the negligent, willful or intentional acts of said Participant, including expenses incurred attendant thereto.

Medical Treatment Permission

I authorize an adult, in whose care the minor has been entrusted, to consent to any emergency x-ray examination,
anesthetic, medical, surgical or dental diagnosis or treatment and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or emergency care facility. The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child or youth pursuant to this authorization.

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