The Registration Form must be electronically signed by both the student and a parent/guardian.
In order to complete your Registration, you must submit a copy of the FRONT and BACK of your health insurance card. Please include the student’s full name if it is not listed on the card. You may email it to firstname.lastname@example.org (PREFERRED method) or mail it to:
Missouri Leadership Seminar, Inc.220 Haley PlaceCarl Junction, MO 64834
You will receive a confirmation email when your registration is complete and has been reviewed by our staff. We will also contact you if we are missing any of your information.
If you have any questions or problems, please contact Alyssa Niemeyer, Director of Recruitment, by email at email@example.com. You may also leave a voicemail at 573.213.9114. Emails and phone messages will be logged and returned within 24 to 48 hours, depending on volume.
a) Agrees to abide by all rules and regulations established by the Missouri Leadership Seminar, Inc. (MLS).
b) Authorizes MLS or any of its agents to provide, obtain, or authorize any reasonable incidental and/or emergency medical treatment for the Participant, in the event of the Participant’s illness, injury, or incapacity, and hereby accepts the responsibility to pay for such treatment;
c) Grants to MLS for any purpose connected with promoting the purposes and goals of MLS, but not for commercial exploitation, the right to use the Participant’s name, voice, and likeness in any writings, photographs, films, and recordings of the Participant while he or she is participating in the Activities, and any biographical information submitted by the Participant to MLS, and to use, reproduce, publish, and distribute the same;
d) Acknowledges that there is an element of risk involved in any activity involving travel outside of one’s own home or community; certifies that the Participant is physically, mentally, and emotionally capable of attending and participating in the activities; assumes all risk of and financial responsibility for any loss or injury to the Participant or others that may occur as a result of the Participant’s negligence or misconduct; and indemnifies and holds MLS harmless from and against any and all costs, claims, demands, charges, liabilities, obligations, judgments, executions, costs of the suit and actual atorneys’ fees incurred or suffered by MLS as a result of, or arising out of, the Participant’s negilgence or misconduct;
2) This Consent and Ackowledgment of Risk shall not be amended, supplemented, or abrogated without the written consent of MLS.
The Participant (and, if the participant is a minor, his or her parent or legal guardian) has read this Consent and Acknowledgment of Risk, and understands and agrees to its contents.