DELEGATE (STUDENT) APPLICATION LEAD Conference Dates October 12 & 13, 2024 This field is hidden when viewing the formNext Steps: Sync an Email Add-OnTo get the most out of your form, we suggest that you sync this form with an email add-on. To learn more about your email add-on options, visit the following page (https://www.gravityforms.com/the-8-best-email-plugins-for-wordpress-in-2020/). Important: Delete this tip before you publish the form.ABOUT YOUYour Name(Required) First Last My Friends Call MeBirth Date(Required) MM slash DD slash YYYY Sex(Required)Please SelectMaleFemaleYour Address(Required) Street Address City ZIP Code Students Cell Phone(Required)Home PhoneParents Cell Phone(Required)Parents Work PhoneStudents Email(Required) Parents Email(Required) School(Required)Adult Shirt Size(Required)Please SelectSmallMediumLargeXLargeXXLargeI am in the 8th grade(Required)Please SelectYesNoTO BE COMPLETED BY PARENT/GUARDIANMEDICAL HISTORY OF APPLICANT: (All medical information must be disclosed for the Delegate's safety and is kept strictly confidential by our professional medical staff members). Vegetarian(Required)Please SelectYesNoDietary restrictionsDoes applicant have any physical limitation or other condition or illness that is being treated that may require assistance while at camp?(Required)Please SelectYesNoIf YES, describeIs applicant currently taking medication?(Required)Please SelectYesNoIf YES, please list what medications are being takenIf YES, please explain condition medication is being used/prescribed forPhysician/Doctor name(Required)PhoneHealth Insurance Carrier(Required)PhoneIN CASE OF EMERGENCY, PLEASE CONTACT(other than parent/legal guardian) Name(Required) First Last Relationship to student(Required)Phone(Required)Your Comments/Questions(Required)Parent/Legal Guardian Consent I give my permission for the named minor Delegate to attend the Rotary District 5340 Leadership, Ethics Aspirations & Determination (LEAD) Conference and to participate in all activities related to LEAD. I have read the Statement of Leadership Responsibility below and I ensure that the Delegate, if attending, will be in full compliance. I hereby assume the risk associated with the Delegate’s participation and agree to save, hold harmless, and indemnify Rotary International (RI), RI District 5340, RI District 5340 LEAD Committee members, Rotary Clubs of RI District 5340, Rotarians participating in LEAD, the camp where LEAD is held, and their committees, members, employees, agents, representatives, and volunteers from any and all liabilities, actions, causes of action, medical or other treatment fees, claims, or demands of any kind or nature whatsoever, which may arise in connection with the student’s participation in LEAD. I take full responsibility for any valuables that the Delegate takes to LEAD. These terms shall serve as a release and an assumption of the risk by the Delegate, the Delegate’s parents, heirs, estate, executor, administrator, guardian, and assignees, and all the members of the student’s family. I authorize RI representatives to arrange for professional care and treatment in case of a medical, dental, or other emergency. I give my permission to the physician, dentist, or other professional selected by the RI representatives to provide the treatment deemed appropriate for the Delegate’s wellbeing. I assume responsibility for any medical, dental, or other treatment fees incurred directly or indirectly because of the Delegate’s participation in LEAD. I certify that all the Delegate’s health concerns have been disclosed and that the information provided above is true and correct. I grant RI representatives permission to use the image of the Delegate for educational and promotional purposes. In addition, I grant RI representatives permission to contact the Delegate regarding other RI programs including Interact, Rotaract, speech and music performance contests, and scholarship opportunities. I agree that a copy, including a copy that is scanned, electronically stored, faxed, etc., of this Student (Delegate) Application, including my consent, shall be as valid and enforceable as an original and may be used for all purposes.Signature(Required)Date(Required) MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
