Launch Leadership : WORKSHOP : Delegate Details

Thanks for registering for Summer Leadership Workshop. We just need a few more details to ensure you have the best week of your summer. You may need numbers from your parents to complete the nitty-gritty (and their approval for the waivers). But trust us, this form is the absolute worst part of Workshop. Enjoy! Let us know if you have any more questions.

Student Full Name (Required)

School in 2018-19 (Required)

Grade in 2018-19 (Required)

Student Email (Required)

Registration confirmation and other correspondence will be delivered to this address.

Student Phone

Parent Name(s) (Required)

Parent Email Address (Required)

Registration confirmation and other correspondence will be delivered to this address.

Parent Phone (Required)

Parent Secondary Phone

Address Line 1 (Required)

Address Line 2

City (Required)

State (Required)

ZIP (Required)

Student Birthdate

I am a member of Student Council or Student Advisory Board (SAB) or other Student Government Organization (Required)

This helps us organize your agenda for the week.

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How did you hear about Launch?

Previous Launch Experience

This section applies to those that have attended one of our services before. If this is your first experience, welcome! You can skip this section. Whew! Less form to complete.

Experience

Check all that apply.

JAM
SLW
One-Day Workshop
Leadership Retreat

The Fine Print Section

Emergency Contact (Other than parent) (Required)

Emergency Contact Phone (Required)

Family Physician

Physician Phone

Health Insurance Provider (Required)

Health Insurance ID Number (Required)

Medical Information

General Health

Please share any health concerns that may affect participation in any way.

Medications

Provide any prescribed medications student will have at Workshop.

Restrictions

Provide any medications of any kind that should not be administered.

Administer

Do not administer any medication without guardian consent.

Allergies

List any allergies the student has.

Additional Comments on Student Health

IEP

I would like Launch to know about my Individual Education Plan (IEP) and/or any disability accommodations that will help me have the best week

IEP

Agreements

Student Agreement

As a student leader and a representative of my school, I agree to abide by all delegate guidelines and will conduct myself in a way that reflects positively on myself and my school.

I agree to the student agreement.

Medical Waiver

I agree, individually and on behalf of Minor, to release and to hold harmless Launch Leadership, Inc., its agents, officers, directors, and employees from liability of any kind, for Minor’s injury, death, or damage to property, that may be sustained by my student while at Workshop.

Media Release (Required)

I agree to the use of my child's image and/or voice in future public relations and marketing materials to promote Launch Leadership.

Would you like to join our e-mail list for information about our annual fundraising event - Fire & Fuzzies?

Demographic Information

The following questions are for demographic purposes only and do not factor in the registration process. Launch does not exclude or otherwise discriminate against any person on the basis of race, color, national origin, disability, or age in admission to, participation in, or receipt of the services and benefits under any of its programs and activities.

Do you qualify to receive free or reduced lunch?

Please select the race/ethnicity (Check all that apply.)

American Indian/Native American
Asian/Pacific Islander
Black/African American
Hispanic/Latino
Middle Eastern/Arab American
White/European American
Prefer not to Answer

Does the delegate identify as an English Language Learner?

Does the delegate identify as having any disability?

You're Almost Registered

Previous Launch Experience

The Fine Print Section

Medical Information

Agreements

Demographic Information