2018 Missouri Leadership Seminar Ambassador Registration Form
The Registration Form must be completed in its entirety prior to submitting. You will not be able to save your information and come back to the form. Please review the required information and ensure that you have the necessary information prior to beginning the form.

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 missourileadership@gmail.com (PREFERRED method) or mail it to:

Missouri Leadership Seminar, Inc.
220 Haley Place
Carl 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 missourileadership@gmail.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.

Ambassador Personal Information
Information will be used for official MLS correspondence and in Ambassador Roster only.
High School *
Please use official and full high school name.
Your answer
First Name *
Your answer
Last Name *
Your answer
Preferred Name (If Different)
For Example, Will instead of William
Your answer
For Housing Purposes, What is your gender? *
If you prefer to describe, please do so below.
Your answer
Phone Number *
Please provide the best phone number to contact you. This number will be used by our staff to contact you.
Your answer
Would you like to receive text message alerts to the number listed above? *
These will be occasional messages to keep you updated and you can opt out at any time
Ambassador's Email Address *
Pre-seminar correspondence will primarily be via email. Please give an email you check often (*Note: some schools block outside emails, make sure if you provide a school email that it does not block emails from missourileadership@gmail.com)
Your answer
Mailing Address *
Your answer
City *
Your answer
State *
Zip Code *
Your answer
County *
Please put the county within the state you live in.
Your answer
Date of Birth *
MM
/
DD
/
YYYY
T-Shirt Size *
All Ambassadors will be provided a free t-shirt. All sizes are Adult sizes.
What careers and career paths are you interested in? *
We will use this information to drive one of dinner panels.
Your answer
Please check the following categories of disorders/conditions/illnesses and surgeries you have had in the PAST, but are no longer subject to. You can further explain each below. (required to answer) *
Required
Please further explain the specific disorder(s)/condition(s)/illnesses(s) and/or surgeries you had and any treatments required. Please provide any information we should be aware of.
Your answer
Please check the following categories of disorders/conditions/illnesses and surgeries you have had in the NOW, but are no longer subject to. You can further explain each below. (required to answer) *
Required
Please further explain the specific disorder(s)/condition(s)/illnesses(s) and/or surgeries you had and any treatments required. Please provide any information we should be aware of.
Your answer
Please list all allergies, including medication, food, insect stings, pollens, etc. Indicate the severity of the allergy and if any emergency action is required. Describe the emergency action if applicable. Respond “None” if you have no allergies. *
Your answer
Please list any medications you will be taking while at MLS. Include dosage information and what time of day you take the medication. You will be required to turn in any medication you bring with you, and it will be provided to you at the appropriate times. You may keep any rescue medications with you (e.g., Epi-Pen, inhaler, etc.), but please list them here and indicate you will be doing so. Respond “None” if you will not be taking any medications while at MLS. *
Your answer
Please describe and explain any limitations on the amount or types of physical activity you can engage in. Respond “None” if you have no activity limitations. *
Your answer
Please list any special dietary needs. Respond “None” if you have no special dietary needs. *
Your answer
Please check all current (up-to-date) immunizations. *
Required
I grant permission for my child to receive the appropriate dosage for his/her age and weight of the following over the counter medications as needed. Please indicate your approval by checking the appropriate medication. *
Required
Health Insurance Information
In order to complete registration, you must submit a copy of the front and back of your health insurance card. You can email it (preferred method) to missourileadership@gmail.com or mail it to 220 Haley Place Carl Junction, MO 64834. Please include the student's full name as it matches registration.
Is the ambassador covered by a health insurance plan? *
Health Insurance Plan Provider *
Your answer
Health Insurance Plan Provider *
Your answer
Health Insurance Plan Number *
Your answer
Name of Insured/Sponsor *
Your answer
Health Insurance Plan Phone Number *
Your answer
Travel Itinerary
Please provide us with information regarding your plans for arriving to and departing MLS.
Arrival Mode of Transportation *
If arriving by CAR, please provide the Name, Relationship, and Cell Phone Number of the driver.
Your answer
If Ambassador will drive himself/herself, please provide the Make, Model, and License Plate of the vehicle.
Keys will be collected at check-in for the duration of the seminar.
Your answer
If arriving by BUS, TRAIN, or PLANE, please provide the Name of Carrier, Bus/Train/Flight Number, and Arrival date and time.
Include any other important information.
Your answer
Departure Mode of Transportation *
If departing by CAR, please provide the Name, Relationship, and Cell Phone Number of the driver.
Your answer
If departing by BUS, TRAIN, or PLANE, please provide the Name of Carrier, Bus/Train/Flight Number, and Arrival date and time.
Include any other important information.
Your answer
Sunday Services Selection
We will be holding religious services on Sunday for the MLS Ambassadors and Staff. All services will be held on the UCM Campus. All ambassadors are required to attend one of the scheduled sessions.
Please Choose One *
Parent/Guardian & Emergency Contact Information
Parent/Guardian Name(s) *
Your answer
Relationship *
Your answer
Parent/Guardian Primary Phone Number *
Your answer
Parent/Guardian Secondary Phone Number
Your answer
Parent/Guardian Email
Provide only if you wish to receive pre-seminar informational emails.
Your answer
Family Physician Name
Your answer
Family Physician Phone Number
Your answer
Please list any secondary emergency contact or other information.
Your answer
Consent and Acknowledgement of Risk
1) IN CONSIDERATION of the right to attend and participate in the Activities described above, the Participant (and, if the Participant is a minor, his or her parent or legal guardian) hereby:

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.

By selecting 'yes' below, you indicate that the Ambassador and Parent/Guardian have read, understood, and agree to the Consent and Acknowledgement of Risk. *
Parent/Guardian Signature *
Sign by typing full name.
Your answer
Ambassador Signature *
Sign by typing full name.
Your answer
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