2019 NYC Youth Leadership Conference (Students)
This is the form for Student participants. Please do not use this form to register as a Parent/Guardian or as a Volunteer.
Email address *
Student's First Name *
Your answer
Student's Last Name *
Your answer
Parent/Guardian First Name *
Your answer
Parent/Guardian Last Name *
Your answer
House number and street *
Your answer
Apt #
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Parent/Guardian Phone Number *
Your answer
Parent/Guardian E-mail Address *
PLEASE MAKE SURE THIS E-MAIL ADDRESS MATCHES THE ONE YOU PUT AT THE TOP OF THIS FORM.
Your answer
Emergency Contact, only if it is not you (NAME AND NUMBER)
Your answer
Student's Birthday *
MM
/
DD
Student's Age *
Your answer
Student's Gender *
Student's Shirt Size *
Please list any allergies, dietary restrictions, or medical concerns the student has.
Your answer
Name of School *
Your answer
Grade *
Grade Point Average (approximately) *
List any activities or interests of the student *
Your answer
List any job or career goals of the student *
Your answer
How did you hear about this year's Conference? *
Your answer
Did the student attend last year's Youth Leadership Conference? *
PARENTAL/GUARDIAN CONSENT *
I understand that checking the box below is a prerequisite to participate in the Youth Leadership Conference. In addition, it is my responsibility to inform the Program Coordinator of any extenuating circumstances (medical, physical, diet, or behavioral) that may affect the well-being of my child or might detract from the learning experiences of the other participants. In addition, I understand that parents and guardians are responsible for ensuring that my participant has no weapons, drugs, or any illegal substance that causes threat to her/him or the general body of participants. I hereby certify that I am the parent and/or guardian of the student named above and that he/she is under the age of twenty-one years. I hereby consent that any media which are taken at events affiliated with the Invictus Greater NYC. Foundation Inc. may be used in conjunction with the project, signed by the adolescent with the same force and effect as if executed by me.
Required
PHOTO AND VIDEO RELEASE *
I hereby grant the Invictus Greater New York City Foundation Inc. the rights of my child's image, likeness, and sound of his/her voice as recorded on audio or videotape without payment or any other consideration. I understand that his/her image may be edited, copied, exhibited, published, or distributed, and waive the right to inspect or approve the finished product wherein his/her likeness appears. I also understand that this material may be used in diverse educational settings within an unrestricted geographic area. Photographic, audio, or video recordings may be used for the following purposes: Conference presentations, Promotional materials, Informational presentations, Online educational courses, or Educational videos. By checking the box below, I understand this permission signifies that photographic or video recordings of my child may be electronically displayed via the Internet or in the public educational setting. There is no time limit on the validity of this release nor is there any geographic limitation on where these materials may be distributed. By checking the box below, I acknowledge that I have completely read and fully understand this release and agree to be bound thereby. I hereby release any and all claims against any person or organization utilizing this material for educational purposes.
Required
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