Name: Hear Us 2023 Chaperone Registration
SKU: 15406
Price: 35.00 USD
Availability: InStock

Name*

First Last

Phone*

Email*

Attendee Type*

Chaperone

Gender*

Preferred pronouns*

School/Group*

Grade Level*

9
10
11
12

Group Sponsor's Name*

First Last

Group Sponsor's Email*

T-Shirt Size*

Dietary Restrictions (if applicable)

Full 9-Digit Home Zip Code*

Consent*

I authorize Hear Us and its staff to use my name and/or photograph/video for promotional and/or publicity purposes regarding Hear Us.

I agree to the publicity release.*

Consent*

I release Hear Us, any of its sponsoring or cooperating agencies, and any other person or organization associated or involved with Hear Us to be held March 29-30, 2023, from any and all liability during Hear Us. I also certify that I am either covered by insurance for any illness, accident, or injury that may occur while at or in route to and from Hear Us, or, if I do not have insurance, I agree to be financially responsible should an illness, accident, or injury occur.

I agree to the liability release.*

Today's Date*

Insurance Carrier*

Name of Policy Holder*

First Last

Group Number*

Policy Number or Medicaid Number*

To Be Completed by Parent/Guardian

Consent*

I give permission for my child to travel to Jefferson City, MO, on a bus with ElevatEd Youth Coalition, on March 29–March 30, 2023. My teen has permission to attend "Hear Us" and engage in all activities except as noted. In case of a medical emergency, I understand every effort will be made to contact a parent/guardian. I authorize emergency care/transportation if needed, and in the event that I cannot be reached, I give permission to any physician, hospital, or other medical facility to perform such medical procedures and medical treatment deemed necessary.

I agree.*

Consent*

I authorize Hear Us and its staff to use the name and/or photograph/video of my teen for promotional and/or publicity purposes regarding Hear Us.

I agree to the publicity release.*

Consent*

I release Hear Us, any of its sponsoring or cooperating agencies, and any other person or organization associated or involved with Hear Us to be held March 29-30, 2023, from any and all liability during Hear Us. I also certify that my teen is either covered by insurance for any illness, accident, or injury that may occur while at or in route to and from Hear Us, or, if I do not have insurance, I agree to be financially responsible should an illness, accident, or injury occur.

I agree to the liability release.*

Parent/Guardian Name*

First Last

Parent/Guardian Primary Phone*

Parent/Guardian Secondary Phone

Today's Date*

Insurance Carrier*

Name of Policy Holder*

First Last

Group Number*

Policy Number or Medicaid Number*