Registration


Young Woman's First Name:

Young Woman's Last Name:

Is the Young Woman going to be 18 years old or above on March 5, 2011:


Young Woman's Email:

Parent/Guardian First Name:

Parent/Guardian Last Name:

Parent/Guardian Email:

Does the Young Woman who is attending the Symposium have any special dietary needs?



If so, what are they?

Does the Young Woman who is attending the Symposium have any Medical Issues that the Symposium Organizers should be aware of?


If so, what are they?

 

 

I acknowledge and agree that participation by the student attendee in the 2011 Young Women's Leadership Symposium in Orlando, Florida may be hazardous for the student attendee and his/her property. I further acknowledge and agree that by submitting this registration I assume the risk of harm, injury, or loss which may occur to the student attendee or any property of the student attendee as a result of his/her participation. I further hereby take full responsibility and release all Symposium organizers, Symposium Sponsors, and all parties of the Florida Diversity Council, as well as the owners, officers, employees, volunteers and agents of each, ("Releases") from any liability, claims, causes of actions, costs and damages, whether caused by the negligence of the Releases or otherwise, resulting from the student attendee's participation.

I further acknowledge that student participation in the 2011 Young Women's Leadership Symposium is voluntary.

I also hereby give my consent for the Releases to seek emergency treatment for the student attendee named above if necessary, and I agree to accept financial responsibility for the costs related to this emergency treatment.

By selecting this checkbox, I submit that I am the student attendee named above and am at least eighteen (18) years of age and fully competent. I further acknowledge and represent that I have read and understand the foregoing provisions and voluntarily consent.

Young Woman's Initials:

Parent/Gaurdian's Initials: