Thank you for registering for our event.

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AUTHORIZATION, CONSENT & RELEASE FORM

This authorization and release pertains to the Enterprise Leadership Conference taking place between 3/5/2014 to 3/7/2014

With my signature, I hereby:

  1. Confirm that I have received, read and understood the contents of the Rotary Expectations of Accepted Students and this full application (6 pages) and that the information provided in this application is accurate at the time of signature.
  2. Confirm that I understand the nature of the ELC experience and the requirements for the applicants’ participation.
  3. Confirm that the student is available to participate on all of the stated dates for the Enterprise Leadership Conference.
  4. Confirm that the student is now a high school junior in credits and expects to be a high school senior in the fall following the event.
  5. Grant to The Rotary Club permission to copyright, use, reuse, publish and republish any photograph/video taken of the student by The Rotary Club or those commissioned by The Rotary Club. This right applies to any reproductions in any form, used alone, in a composite or with any printed matter or advertising copy, for any purposes of trade, advertising, publicity, promotion or education, without restrictions or limitations.We release The Rotary Club and its agents from liability resulting from any distortion, blurring, alteration, optical illusion or placement in a composite, intentional or otherwise, which may occur in the taking, processing, reproduction, publication or distribution of such image(s). I waive the right to approve the image(s) or use. I have read this agreement and release all liability and understand the terms.
  1. Grant to The Rotary Club permission to share the student’s e-mail address with other event participants for the purposes of preparation and team building. I understand that this information will not be sold or used in relation to any commercial activity.
  2. Acknowledge the requirement to attend the Orientation session and agree to do so.

STUDENT CONSENT AND WAIVER

With my signature, I hereby:

  1. Acknowledge and agree to the points outlined above.
  2. Confirm that I will abide by the rules and expectations of the Conference, including conducting myself in amanner that will bring positive credit to my school, my parents, the sponsoring Rotary Clubs and me.
  3. Agree that once I am signed into the Conference, I will not leave without the permission of the ELCChairman and the permission of my parents.

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[one_second]Student Signature (Must Sign)______________________[/one_second][one_second]Date________________________[/one_second]

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PARENT/GUARDIAN CONSENT AND WAIVER

With my signature, I hereby:

  1. Acknowledge and agree to the points outlined above.
  2. Confirm that I am the legal parent/guardian of the applicant, and that I am listed as the primary contact inthis application
  3. Authorize, in the event of emergency, the bearer of this form to request, obtain, contact, or direct theprovision of medical care for the named, student should this be necessary during the period of the Enterprise Leadership Conference activities. I accept all financial responsibility for such medical care as may be rendered.
  4. Consent and grant the applicant permission to attend and be transported by the Rotary Clubs’ Enterprise Leadership Conference during
  5. In consideration of the selection of said student for participation in the Conference activities and the education, training, recreation and fellowship afforded thereby, I, for myself, heirs, executors, administrators, and assigns, hereby waive and release all rights and claims against the Rotary Club, their officers, agents, employees, representatives, members, successors, and assigns for any damages or injuries which may be sustained by said student in connection with or for participation in the Enterprise Leadership Conference.
  6. Consent to allowing the information in this application to be shared with other local Rotary Clubs in the event that the applicant is not selected for this event.
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[one_second]Primary Parent/Guardian Signature (Must Sign)______________________[/one_second][one_second]Date________________________[/one_second]

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[one_second]School Representative Signature (Must Sign)______________________[/one_second][one_second]Date________________________[/one_second]

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[one_second]School Representative Name (BLOCK CAPITALS)______________________[/one_second][one_second]Phone Number________________________[/one_second]

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