2019 Youth Leadership Conference Student Application
Dear Friends of YLC,

We appreciate your interest in the 2019 Youth Leadership Conference. Please complete the registration form below if you are able to attend the entire duration of the conference. We will not be allowing students to arrive late or leave conference early so that students can experience the program in its entirety and also to prevent disrupting the student group dynamic.

Upon completion, please submit the registration payment via our Paypal link, our Venmo account (@YLChouston), or by mailing a check payable to "Youth Leadership Council" to 5233 Bellaire Blvd, Suite B, Box #215, Bellaire, TX 77401. Early Registration is $225 on or before April 30, 2019; Registration is $250 after April 30, 2019.

Your registration for the 2019 Youth Leadership Conference is considered complete when both your application and payment are received by YLC. Payments by check are based on the postmark date. In order to qualify for the Early Registration discount, both your application and payment must be received by April 30th. Please complete the online application and submit payment in a timely fashion prior to the above deadlines to qualify for the discount and secure your position at YLC. We highly recommend that you register and submit payment as soon as possible as we do reach our max capacity quickly.

You will receive a confirmation email from a YLC representative within 2 - 3 business days upon completion of the application. Please note that refunds will not be given if you withdraw your registration within 14 days of Conference. Please feel free to contact me with any questions or concerns at registrar@ylc.net.

Best regards,
Katherine Chung
Registrar
Youth Leadership Council

Student Information
Only 1 student per application. If you have a sibling or relative that wants to attend YLC, please have them fill out the application separately.
First Name *
Your answer
Last Name *
Your answer
Address *
Example: 123 Sesame St.
Your answer
City *
Your answer
State *
Zip Code *
Your answer
Birth Date *
Format: mm/dd/yyyy
Your answer
High School *
Your answer
Grade Level *
What grade are you attending in Fall 2019?
Gender *
Student Contact Number *
Your mentor will be calling you about 1 week before conference. Format: (###) ###-####
Your answer
Email Address *
We will inform you of your acceptance to YLC and notify you of important updates regarding the conference. We will never use your email for spam.
Your answer
How many YLC conferences have you attended (not counting this year)? *
T-shirt Size *
If you are accepted to YLC, you will be given a free Conference t-shirt.
Would you be interested in performing in Cafe Y? *
Cafe Y is a forum at YLC where students can showcase their talents (e.g. dancing, playing an instrument, spoken word, martial arts, etc.)
Parent Information
While there has never been a serious incident in YLC's history, it is important that YLC volunteers have the contact information of one of your parents in the event of an emergency.
First Name *
of Student's Parent or Guardian
Your answer
Last Name *
of Student's Parent or Guardian
Your answer
Relation to Student *
Address *
Example: 123 Sesame St.
Your answer
City *
Your answer
State *
Zip Code *
Your answer
Parent's Mobile Phone *
format: (###) ###-####
Your answer
Parent's Home Phone *
format: (###) ###-####
Your answer
Parent's Alternate Phone Number
format: (###) ###-####
Your answer
Email Address *
of Student's Parent or Guardian
Your answer
Is parent or guardian fluent in English? If not, what is the parent or guardian's primary language? *
Medical Authorization Form
I do hereby authorize The Youth Leadership Council and its agents or representatives to consent, on my behalf, to any medical/hospital care or treatment to be rendered to him or her upon the advice of any licensed physician. I agree to be responsible for all necessary charges incurred by any hospitalization or treatment rendered pursuant to this authorization.
Parent or Guardian - Agree to Medical Authorization *
By checking 'Yes' below, you indicate that you have read, understood, and agree to the Medical Authorization.
Required
Parent or Guardian's Signature *
Your answer
Parent or Guardian's Driver's License Number *
For Verification purposes only
Your answer
Does the Student have any medical conditions? If there are none, please state NONE. *
i.e. Asthma, allergies, diabetes, heart conditions, etc.
Your answer
Does the Student have any dietary requirements, food and/or drug allergies? If there are none, please state NONE. *
i.e. Penicillin, vegetarian, vegan, peanut allergy, shrimp allergy, etc.
Your answer
Is the Student on any prescription or over the counter medications? If there are none, please state NONE. *
Please state the medication, dose and frequency.
Your answer
Alternate Emergency Contact Person: *
Individual other than Parent or Guardian named above. Please include full name.
Your answer
Alternate Emergency Contact's Phone Number: *
Format: (###) ###-####
Your answer
Medical Insurance Provider: *
If None, please state NONE.
Your answer
Medical Insurance Policy or Group Number:
Your answer
YLC Release, Waiver and Indemnification Agreement
I, parent/legal guardian of the above named individual, or the individual him or herself if above the age of majority in consideration for being allowed to participate in the Youth Leadership Conference (the “Conference”) and engage in the activities related to being a participant hereby freely, voluntarily, and without duress executes this Release, Waiver of Liability and Indemnification Agreement (the “Release”) under the following terms:

Release and Waiver: I hereby release and forever discharge and hold harmless the Youth Leadership Conference, Inc. and its officers, directors, employees, or agents (collectively “YLC”) from any and all liability, claims, and demands of whatever kind or nature, either in law or in equity, which may arise or may hereafter arise from my son or daughters activities with YLC. I understand that this Release discharges YLC from any liability or claim that I may have against YLC with respect to any bodily injury, personal injury, illness, death, or property damage that may result from my participation in this year’s Conference, including harm resulting from my son or daughter’s own negligence or the negligence of other participants. I also understand that YLC does not assume any responsibility for or obligation to provide financial assistance or other assistance, including but not limited to medical, health, or disability insurance. I enter into this agreement for myself, my son or daughter as well as for his or her heirs, assigns and legal representatives.

Indemnification: I agree to indemnify and defend YLC and hold them harmless from any and all claims, causes of action, damage judgments, costs or expenses, including attorney fees which in any way may arise from Conference which includes but are not limited to damages to or destruction of property, injury, death or any liability arising from the acts or negligent acts of my son or daughter.

Acknowledgement of Policies and Procedures: I acknowledge that my son or daughter and I have read, know, and agree to all of the policies and procedures relating to my participation in the Conference. I understand that the safe and proper use of all facilities, equipment or participation in the activity is dependent upon carefully following these policies and procedures.

Assumption of Risk: While YLC makes every effort to make its activities as safe as possible, I understand that Conference may include activities that may be inherently hazardous. I agree to allow my son or daughter to participate with full knowledge of the dangers and potential injuries involved. I hereby expressly and specifically assume the risk of injury or harm and releases YLC from all liability for injury, illness, death, or property damage resulting from my son or daughters participation in this year’s Conference.

Payment for Damages: I agree to pay for any and all damages to any property caused by my son or daughter, negligently, willfully or otherwise.

Photographic Release: I do hereby grant and convey unto YLC all rights, title, and interests in any and all photographic images and video or audio recordings made by YLC during my son or daughter’s activities with YLC, including, but not limited to, any royalties, proceeds, or other benefits derived from such photographs or recordings.

Arbitration: I expressly agree that this Release is intended to be as broad and inclusive as permitted by the laws of the State of Texas, and that this Release shall by governed by and interpreted in accordance with the laws of the State of Texas. I agree that if there is any dispute with YLC, it will be resolved by binding arbitration in the State of Texas, based upon the rules of the American Arbitration Association and Texas law.

Jurisdiction: This Assumption of Risk, Waiver, and Release from Liability shall be governed in all respects by the laws of the State of Texas. The parties agree to use the State of Texas for Jurisdiction and the County of Harris as Venue for any disputes between the parties related to this Assumption of Risk, Waiver, and Release from Liability.

Severability: I agree that in the event that any clause or provision of this Release shall be held to be invalid by any court of competent jurisdiction, the invalidity of such clause or provision shall not otherwise affect the remaining provisions of this Release which shall continue to be enforceable

Both Student and Parent/Guardian Agrees to the Release, Waiver and Indemnification Agreement *
Required
Both Student and Parent/Guardian understand that it is necessary for the student to be checked-out by their parent. If a student is to be checked-out by someone other then their parent/guardian, the Student Checkout Form must be filled out and the designated individual must present the form to YLC at the time of checkout. Students who have driven themselves do not need a parent present to check-out. *
Required
Student's Signature *
Sign by typing your full name
Your answer
Student's Driver's License Number. If none, please state NONE. *
For Verification purposes only
Your answer
Parent or Guardian Signature *
Sign by typing your full name
Your answer
Parent or Guardian's Driver's License Number *
For Verification purposes only
Your answer
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