2021-2022 OMEGA U Student & Parent Application
Form serves as an application form for Omega U participants and parents.  Information provided by students/parents help  create communication channels and program offerings.In addition, this application includes a general wavier of liability, field trip permission, photo release form, and code of conduct policy. Omega U retains the right to remove any student based on code of conduct in protection and safety of other students and mentors/caregivers of the program.
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Parent Email Address *
Student Email Address
Alternate e-mail address
Parent/Student Home Address *
Primary Contact Number *
Secondary Contact Number
Student First Name *
Student Last Name *
Parent Name *
Student Birthday (17/11/1911) *
Student's School *
Grade of Student *
Who does student live with?
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Was student in Omega U last year? *
Students Grade Point Average  (Please select to best of your knowledge)
Student's shirt size (Adult Sizes) *
How did you hear about Omega U? *
Omega U Code Of Conduct Policy
This contract recognizes the important role and responsibility of the student, parent, school, and Omega U in working together to support a student’s progress and successful development in life.  The student will make best effort to attend all Omega U events and activities as scheduled. Students will act and behave with respect to parents, school administrators, teachers, mentors, fellow students at all times. Parents will ensure transportation child(s) to and from pick-up and drop off locations at corresponding times per activity and event for Omega U.  Students will adhere to the code of conduct for the Prince William County School at all times.  Omega U Committee remains the right to dismiss any child/participant from the Omega U program or attending any affiliated Omega U sponsored event at all times.  Students that are suspended from school is automatically suspended from all attending all Omega U sponsored events on and off PWC campus locations.  Omega U and Pi Lambda Lambda has the right to receive back any/all Omega U attire in the event the child has violated Omega U code of conduct policy at the discretion of the Omega U committee. In the event that the child or parent cannot return the attire, Omega U has the right to has for full value of the attire that was given to the child to participate in Omega U sponsored events. I hereby acknowledge I have read and understand the Omega U code of conduct policy. *
Parent/Guardian Acknowledgment & Field Trip Permission
I hereby acknowledge the contents of the Omega U application and consent I am of at least the age of 18 and or legal parent/guardian of child/dependent to participate in all Omega U events, activities, and field trips. I understand and agree that in the event an Omega U sponsored event is canceled for any reason, I/we will not hold Prince William County Public Schools, Prince William County School Board, Potomac Middle School, Omega Psi Phi, and Pi Lambda Lambda employees, agents, or members for any reimbursement or monies invested in any event. As legal guardian, I acknowledge all responsibility to make proper arrangements for my child to attend and be picked up from all sponsored Omega U events. *
Omega U Photo Release Form
I hereby grant Omega U, Pi Lambda Lambda of Omega Psi Phi Inc., of Dumfries VA permission to use my likeness in photographs and/or video in any and all of its publications, including Web space, and in any and all other media, whether now known or hereafter existing, controlled by Pi Lambda Lambda, in perpetuity, and for other use by the Pi Lamda Lambda. I will make no monetary or other claim against Pi Lambda Lambda or Omega Psi Phi Inc., for the use of the photographs and/or video. *
Waiver of Liability, Assumption of Risk, and Indemnity Agreement Waiver:   In return for being permitted to participate in the Omega U Mentoring program, including any associated use of the premises, facilities, staff, equipment, transportation, and services of PLL/OPPF/3rd District, I, for myself, heirs, personal representatives, and assigns, do hereby release, waive, discharge, and promise not to sue The Regents of the Omega U Program, its mentors, chapter officers, chapter members, and agents (“PLL”), from liability from any and all claims, including the negligence of PLL/Omega U, resulting in personal injury (including death), accidents or illnesses, and property loss, in connection with my participation in the Activity and any use of PLL, PWCPS premises and facilities. Omega U Mentoring Program: July 2020 - June 2021; Assumption of Risks:   Participation in The Program carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injury.  The specific risks vary from one activity to another, but the risks range from 1) minor injuries such as scratches, bruises, and sprains, to 2) major injuries such as eye injury, joint or bone injuries, heart attacks, and concussions, to 3) catastrophic injuries such as paralysis and death.   Indemnification and Hold Harmless:  I also agree to indemnify and hold The PLL/Omega U harmless from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorney’s fees, arising out of my involvement in The Activity, and to reimburse it for any such expenses incurred. Severability:  I further agree that this Waiver of  Liability, Assumption of Risk, and Indemnity Agreement is intended to be as broad and inclusive as permitted by law, and that if any portion is held invalid the remaining portions will continue to have full legal force and effect. Governing Law and Jurisdiction:  This Agreement shall be governed by the laws of the State of Virginia, and any disputes arising out of or in connection with this Agreement shall be under the exclusive jurisdiction of the Courts of the State of Virginia. Acknowledgment of Understanding:  I have read this Waiver of Liability, Assumption of Risk, and Indemnity Agreement, fully understand its terms, and understand that I am giving up substantial rights, including my right to sue.  I confirm that I am signing the agreement freely and voluntarily, and intend my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law. *
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