Leadership Workshop Registration Form

LEADERSHIP WORKSHOP REGISTRATION FORM

Use this form to register for the leadership workshop. Completion of this form, acceptance of payment, and signature at the end constitute a binding registration and consent to the policies, medical release, and liability release contained herein. Program Provider information is requested below for administrative and legal identification.

Program Identification

Program Provider:

Participant Information

Participant is a minor under age 18: If participant is a minor, parent/guardian information is required below.

Parent / Guardian Information (if applicable)

Emergency & Medical Information

Workshop Details & Payment

Workshop Title:

Workshop Date(s):    Location:

Start Time:    End Time:

Payment Method: Full payment Installment plan

Amount Paid Now (USD): Payment Date:

Permissions, Release & Policies

Photo/Video Release: I authorize the Program Provider named above to use photographs, audio, and video recordings of the Participant taken in connection with the workshop for promotional, educational, and archival purposes without compensation. I release the Program Provider and its representatives from any claims arising from such use.

Medical Treatment Authorization: In the event of an emergency, I authorize the Program Provider and its agents to obtain necessary medical treatment for the Participant. I agree to be responsible for any costs associated with that treatment. This authorization includes transportation to medical facilities as determined necessary by event staff.

Liability Release and Assumption of Risk: Participation in leadership activities includes activities that may involve physical movement, group exercises, and experiential learning. By signing below, the Participant (or Parent/Guardian) acknowledges that they understand the nature of the activities, accept the risks inherent in participation, and voluntarily assume full responsibility for any injury, loss, or damage that may occur. To the fullest extent permitted by law, the Participant releases and agrees to hold harmless the Program Provider, its officers, directors, employees, agents, volunteers, and instructors from any and all claims, liabilities, costs, or expenses (including attorney fees) arising from or relating to participation in the workshop, except to the extent caused by the Program Provider's willful misconduct or gross negligence.

Behavioral & Academic Conduct: Participant agrees to comply with workshop rules and the instruction of staff. Serious misconduct or violation of safety rules may result in removal from the program without refund. Participant acknowledges that removal for cause does not obligate the Program Provider to refund fees already collected.

Privacy & Data Use

Participant information will be used for program administration, emergency contact, and health/safety purposes only, and will be stored in accordance with standard educational program practices. The Program Provider will not sell personal information to third parties. By signing below, Participant consents to the collection and use of the data provided on this form for those administrative purposes.

Acknowledgment & Certification

By signing below, I certify that I am the Participant named above, or I am the Parent/Legal Guardian of the Participant named above and have authority to enroll the Participant in this program. I certify that the medical information provided is accurate to the best of my knowledge and that I have disclosed all information relevant to the Participant's ability to safely participate. I have read, understand, and agree to the terms, releases, and policies set forth in this form.

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