Registration Form: 2022 Empowering Youth Leadership Institute

Empowering Youth Leadership Institute will begin on Monday, July 25th at 3:00pm and end Wednesday, July 27th at 12:00pm.

Please fill out this permission form and we will send you a welcome registration packet at the beginning of July. With questions, please contact EmpowerMT at info@empowermt.org

Contact Information

Participant's Name

First Name

Last Name

Participant's Date of Birth

(mm/dd/yyyy)

Pronouns (She, He, They, Two-spirit, etc.)

School or Organization

Grade level

Telephone number

Verify Email

Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Role:

Student

Educator

Community Member

Dietary Restrictions

T-shirt Size

Medical conditions & medications

(if not applicable write none.)

Health Insurance info (Policy provider & number)

(if not applicable write none.)

Please pick an option for transportation

Please arrive at Camp Paxson at 3:00pm on Monday, July 25th.

I will take the group bus

I will be using my own transportation

How would you like to receive your welcome packet?

U.S. mail

Parent Guardian info:

For participants 18 and under

Parent/Guardian Name

First Name

Last Name

Pronouns (She, He, They, Two-spirit, etc.) Copy

Relationship to child

Parent/Guardian Phone number

Parent/guardian Email

Verify Email

Parent/Guardian address (if different than above)

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Emergency contact info:

Emergency Contact Name

First Name

Last Name

Emergency contact phone number

Emergency Contact relationship to participant:

Waiver & Release:

By checking the boxes below, I apply my legal initials indicating I have carefully read, clearly understand, and voluntarily sign this waiver and release agreement.

COVID-19 safety protocol

I understand that EmpowerMT will be following CDC and Missoula County Health department's safety protocols and every effort will be made to ensure safety and wellbeing. I can contact EmpowerMT any time at 406-541-6891 to learn more.

Voluntary participation

I acknowledge that my (my child’s) participation in EmpowerMT’s programs is voluntary and has inherent risks and dangers that cannot be eliminated. I know I have the opportunity to discuss any concerns with the EmpowerMT staff prior to my (my child’s) participation in EmpowerMT’s programs. I can contact EmpowerMT any time at 406-541-6891.

Prevention of harm

I understand that EmpowerMT employees and volunteers will try to prevent accidents. However, I fully understand that some activities I (my child) will participate in may involve inherent risks regardless of all feasible safety measures being taken by EmpowerMT.

Liability for personal property

I agree to accept responsibility for any loss, damage, or injury to my (or my child) that occurs during my (my child’s) participation in this program that is not the result of fraud, willful injury to a person or property or the willful or negligent violation of the law.

Transportation

For participants 18 and under

I give permission for my child to ride in buses, cars, and other vehicles that are hired, rented, or driven by EmpowerMT staff and volunteers.

Emergency care

In the event it becomes necessary for the EmpowerMT employees and/or volunteers to obtain emergency care for me (my child), EmpowerMT nor its employees and volunteers will assume financial liability for expenses incurred because of an accident, injury, illness and/or unforeseen circumstances. I authorize EmpowerMT employees and volunteers to obtain all necessary emergency medical care and authorize any licensed physician and/or medical personnel to render necessary emergency treatment to me (my child).

Photo & video release & consent

EmpowerMT may photograph and record me (my child). I grant EmpowerMT permission to use and publish images and videos taken during EmpowerMT programs for publicity, promotional, and/or educational purposes (including but not limited to publications, presentations, newspapers, the internet, and other media sources). I do this with full knowledge and consent and waive all claims for compensation for use, or for damages.

By typing my name below, I apply my legal signature indicating I have carefully read, clearly understand, and voluntarily sign this permission form with the waiver & release agreement.