Learning to Lead

Registration

Note: Registration deadline is June 15, 2015

Guardian Information

*First name:


*Last name:


*Address:


*City:


*Zip Code:


*Phone:


*Email:



Participant Information

*First name:


*Last name:


*Date of Birth:  
 (MM/DD/YYYY) 

*Grade You'll Enter in August:


*School Name:


*T-Shirt Size:


*Payment Method: 

Credit/Debit Card OR Checking/Savings Account

I will mail my check (Payments will not be accepted at the door)

   Please mail check to:
    Lewis University
Attn: Lesley Page, Unit 1085 (BE 153)
One University Parkway
Romeoville IL 60446

Comments:



Participant Waiver Agreement

I hereby grant permission for
(the Participant) to attend and fully participate in the Learning to Lead Youth Summer Program, and I hereby release Lewis University, its Trustees, its agents and employees from any liability therein. I am aware of no condition which would prohibit the Participant from participating in any activities of the Program therein.

(the Participant) has received a physical examination within the last twelve (12) months.

By my signature affixed below, I acknowledge the risk involved and assume all responsibility for the safety and conduct of the Participant while using the Lewis facilities. Participants agree to follow and be bound by the rules and regulations as outlined in the Lewis University Handbook and all local, state and federal laws.

I, the undersigned, acknowledge that I have read and understand the above agreement and agree to be bound by the terms of this agreement

*Name of Parent/Guardian (printed name will serve as an electronic signature):


Date: 4/18/2015

A Parent/Guardian must complete the following information as well:

  1. *I grant permission for Emergency medical care to be given to my child.
    Yes
    No

  2. *I grant permission for my child to be photographed/videotaped at the Program.
    Yes
    No

  3. *Does your child need any special accommodations at this Program? If yes, please describe:
    Yes  
         Describe:
    No

  4. *Does your child have any food/dietary restrictions or allergies? If yes, please describe:
    Yes 
         Describe:
    No

  5. *List an Emergency Contact (Name/Phone) that can be reached during Program hours:


REFUND POLICY
All Sales are final.

* I AGREE