Youth Leadership Day Registration

2019 Youth Leadership Day Registration

SATURDAY, FEBRUARY 23, 2019   |   REGISTRATION BEGINS AT 7:30 AM

PHOENIX COLLEGE, 1202 W THOMAS RD, PHOENIX, AZ 85013

Our youth are our future leaders and we are strongly committed to their success. Each year the Phoenix Indian Center hosts a Youth Leadership Day, planned closely with local organizations, focusing on leadership, college and career readiness, substance abuse preventions, and cultural enrichment. This FREE conference is open to all self-identifying American Indian high school students from across the Phoenix-Mesa Metropolitan Area and surrounding communities.


STUDENT INFORMATION

Student Name:*
Gender:*
Grade:*
Date of Birth:*
Tribal Affiliation:*
Graduation Date:*
High School:*
Student Phone:
Student Email
Physical Address:*

PARENT/GUARDIAN INDFORMATION

Parent Name:*
Parent Phone:*
Parent Email:*
Parent Sessions:*

MEDICAL INFORMATION

Allergies (including food and medication):*
Medications:*
Special Health Conditions:*

TRANSPORTATION & CHAPERONE INFORMATION

Please indicate which method of transportation your child will be taking to and from the Leadership Day:*
Chaperone Name (if applicable):
Chaperone Phone:
Chaperone Email:
Chaperone Sessions:

RESPONSIBILITIES & AGREEMENTS

This Release, Indemnity, and Assumption of Risk statement covers all activities, events, sessions, meals, occurrences, participation, observation, and travel between activities, associated with the 2019 Youth Leadership Day. I consent for my child to participate in the 2019 Youth Leadership Day. I agree to release, waive, and hold harmless Phoenix Indian Center or other organizations from any claims, liability, or responsibility for any injury, illness, damage or loss. I further consent to the provision of emergency medical treatment for my child to the extent necessary. I will note all allergies, medications and special conditions in this form. If I have any concerns about my child’s ability to participate in any event or activity associated with the Phoenix Indian Center, I agree to discuss my concerns with my child’s physician before signing this form.

Electronic Signature Option:
By typing your name below, you are consenting to use an electronic signature to submit this registration form and indicate that you want your child to participate in the 2019 Youth Leadership Day at Phoenix College.
Parent/Guardian Signature:*
Date:*

PHOTO/VIDEO/AUDIO WRITTEN INFORMATION RELEASE

I hereby authorize and give full consent to PHOENIX INDIAN CENTER, INC. to reproduce, publish, display and/or copyright all written information, live broadcasts, still or motion photographs/videos and/or voice recordings taken by them or agents, in which I appear.

I release PHOENIX INDIAN CENTER, INC. and its funders, representatives and assignees from any and all claims, demands and causes of action of every nature and kind arising out of or connected with the use of these broadcasts, photographs, videos and/or voice recordings.

I further agree that PHOENIX INDIAN CENTER, INC. may use or cause to be used, these items for any and all exhibitions, public display, publications, commercial art and advertising purposes without limitation or reservation or any fee.

Student Signature*
Parent/Guardian Signature*
Date*
Would you like to receive our e-newsletter with information about upcoming events?*