10^th Annual EMBODI "Men of Color" Conference

REGISTRATION & PERMISSION FORM(For Student under 18)

Priority Registration Deadline: September 17, 2020

To be completed by participants 18 and over OR Parent/Guardian for participants under 18.

PARTICIPANT'S INFORMATION

Full Name : *

Age: * *

Address: *

City: *

State:

Zip Code: *

Participant is a:

Middle School student

High School student

College student

PARENT/GUARDIAN CONTACT INFORMATION AND PERMISSION

Emergency Contact(1): *

Phone number: (000)000-0000 * *

Emergency Contact (2): *

Phone number: (000)000-0000 * *

High school seniors and college students have the opportunity to apply for a $500 scholarship to apply toward your college expenses. Please visit our EMBODI page, and follow the directions to apply. If you are awarded the scholarship, you must attend the conference to accept it, or send a representative to accept the scholarship for you.

PERMISSION TO PHOTOGRAPH

As part of the EMBODI program, photography serves as a partial means to fulfill the objectives designed to accomplish goals by showcasing the young men. Some examples include: self-esteem projects, historical record, newspaper and awards. The use of photography will only be used to augment the development of the young men in a very positive and constructive manner. As a result, your permission is needed in order for us to use photography as part of our endeavor.

I give the sponsoring organizations permission to publish/display pictures of me/my son participating in this event.

Yes

NOTICE TO PARENT/GUARDIAN OF SENSITIVE INFORMATION (For participants under the age of 18)

Age appropriate information on sensitive issues, such as religious beliefs, human sexuality, cultural and family values, AIDS, sexually transmitted diseases, substance abuse, suicide and teen pregnancy are issues that may arise during this workshop. By obtaining your permission, you will allow a healthy interaction that will hopefully provide your son with the confidence needed to come to you, the parent/guardian, for your influence.

Signature of Responsible Party
(Must be signed by Parent/Guardian
or students over 18): *

Date:

Phone number of Responsible Party : (000)000-0000 * *

Email address of Responsible Party: * *

Application Submittal Directions: (By submitting this registration form, I certify that my child has my permission to attend.)

To prevent duplicates, click the SUBMIT button only once.

10th Annual EMBODI "Men of Color" Conference

REGISTRATION & PERMISSION FORM(For Student under 18)

Priority Registration Deadline: September 17, 2020

10^th Annual EMBODI "Men of Color" Conference