Leadership for Teens Registration

Congrats! You are getting the special discounted price!
Total price: $155

Registration Form - Leadership For Teens Workshop
Which workshop date would you like to attend? (Sunday June 19 and 26 are not available)
What is leadership and why is it essential? *
If you could learn anything at Leadership For Teens Workshop, what would it be? *
Participant Name *
Participant Birthday *
Participant Email *
Participant Cell #
Participant's Grade *
Participant's school *
Please share any dietary concerns or restrictions.
Participant Honor Code *
To be completed by Parent/Guardian
Parent / Guardian Name *
Address *
Parent / Guardian Email *
Parent / Guardian Cell Phone # *
Emergency Phone # *
How did you hear about the workshop?
What do you hope your child will achieve as a result of this workshop? *
Can you make it at the end of the day from 5:00 pm - 6:30 pm for your child? We want to make this experience for your child and family last. *
Your child will share their digital portfolio with you. You will see what we experienced and much more.
I will be there!
I am unsure, I may be able make it based on the day.
Sorry, I can't make it.
Parent Consent and Release Terms for the Leadership For Teens Workshop

I, as­ a parent/guardian of my child, hereby give consent and permission for my son/daughter, “the Participant” to attend and participate in the Innovative Leader Workshop, “the Workshop”.

INDEMNITY. I, on behalf of myself, the Participant, and my heirs, successors, assigns, and any other persons or entity claiming through or under any of them, agree to RELEASE, INDEMNIFY, and HOLD HARMLESS BuildMyIdea.org, Ryan Makhani, its founders, coaches, instructors, members, staff, volunteers, sponsors and agents, including the organizers, and staff associated with the Workshop (collectively, the “Indemnitees”) from and against any and all losses, claims, damages, causes of action, liabilities, costs, and expenses which may be asserted against the Indemnitees, if any, of every nature whatsoever, known or unknown, which arise out of or are connected with any damages to person or property as a result of the Participant’s participation or any other person’s participation in the Workshop; any injury or death, including that arising, in part or whole, from the sole or contributory negligence of the Indemnitees, occurring during or related to the Workshop; and any policies, procedures, conduct, or negligent act or omission of the Indemnitees.

MEDIA. I, hereby consent to the participation in interviews, the use of quotes, and the taking of photograph(s) and video recording(s) of the Participant during the Workshop. The photograph(s) and video recording(s) will depict images of the Participant’s work and activities in the Workshop. I also grant the Indemnitees the right to edit, use and reuse said photograph(s) and video recording(s) of the Participant in any form of media sponsored by BuildMyIdea.org including the publishing of any printed media, digital media, or internet distribution in conjunction therewith. I understand that photograph(s) and video recording(s) of the Participant participating in Workshop activities may be published on BuildMyIdea.org website, social networks, other websites and printed materials. I also hereby release the Indemnitees from all claims, demands, liabilities in connection with the above photograph(s) and video recording(s). I agree that all photograph(s) and video recording(s) will remain the property of BuildMyIdea.org and Ryan Makhani. I understand that the Participant will receive no compensation for his/her appearance in photograph(s) and video recording(s). I also understand that “Media” including but not limited to journalists, reporters, writers, bloggers, marketers, advertisers and other citizen or traditional media employees or volunteers may be present at the Workshop and the Participant may be photographed or videotaped by the Media.

MEDICAL. I, hereby give my consent to any medical or surgical treatment which the Participant may need and which arises in connection with the Workshop; provided, however, nothing contained herein shall be deemed an obligation to provide any such medical or surgical treatment. I understand that the Indemnitees do not carry healthcare insurance that covers the Participant and therefore, I am solely responsible for the cost of all medical and surgical treatment. In the event of a medical emergency, I do hereby authorize emergency medical treatment or attention to be administered to the Participant by a qualified staff member. I also give permission for the Participant to be transported by ambulance or aid car to an emergency center or hospital for treatment. In the event that I cannot be contacted, I further consent to the medical treatment and procedures to be performed for the Participant by a licensed physician or hospital when deemed immediately necessary or advisable by the physician to safeguard the Participant’s health and life. I will be responsible for all expenses incurred for medical treatment of the Participant in case of an emergency.

TRANSPORTATION. I, hereby consent that the transportation to and from the Workshop location is my responsibility. I understand that it is my responsibility to drop the Participant at the Workshop location by 9 a.m. on and pick up the Participant by 6:30 p.m. or arrange for transportation. The Indemnitees take no responsibility and are not liable for transportation or lack of transportation to and from the Workshop.

The parties agree that any controversy or claim arising out of or relating to this Consent and Release Form shall be referred to a local mediation/dispute resolution center in Houston.

The parties further agree that should any part of this consent and release form be determined to be invalid or without full legal effect, such determination shall not invalidate the remaining portions thereof, which shall remain in full force and effect.

I have read and sign this consent and release form and intend it to be a complete and unconditional release of all liability to the greatest extent allowed by law.
Digital Signature *
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