Missouri Legislative Black Caucus Foundation, Inc. Youth Leadership Conference Application Hosted by the University of Missouri July 22-24, 2012

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1 Missouri Legislative Black Caucus Foundation, Inc. Youth Leadership Conference Application Hosted by the University of Missouri July 22-24, 2012 The Missouri Legislative Black Caucus Youth Conference will be held on the campus of the University of Missouri in Columbia, MO from July 22-24, This year s theme is Fulfilling the Promise: Every-one, Every-day, Every-way. A Blueprint for Sustainability. There is no fee for students to participate in this conference. Completed applications must be submitted to the Missouri Legislative Black Caucus Foundation, Inc. by June 22, 2012 to be considered. Students traveling over five hours to the University of Missouri campus have the option to depart the morning of July 25, These arrangements must be approved in advance by the University of Missouri. Please fill out the application in its entirety. A checklist is provided below to ensure you submit a thoroughly completed application. There should be: Conference Application (Student, Parent/Guardian, Emergency, and Medical Information) Student Leadership Information Student Summary of Intent Public Information Release Form* Release of Liability Form* Consent for Student s Participation Form* Medical Treatment Form* *Parent/Guardian signature required Completed applications are due by June 22, 2012 and should be sent to: Missouri Legislative Black Caucus Foundation Inc Paseo Blvd, Suite 102 Kansas City, MO Toll free (877) or (573) Fax (816) For questions, comments, or concerns, please contact: Sheron Fulson 4609 Paseo Blvd, Suite 102 Kansas City, MO MLBCF@aol.com Phone: (573)

2 Missouri Legislative Black Caucus Foundation, Inc. Youth Leadership Conference Application Hosted by the University of Missouri July 22-24, 2012 (Please Print or Type) STUDENT INFORMATION Name (Last, First MI): Address: City: State: Zip: Phone: School Name: of Birth: Age: _ Gender: Grade Level (Please select one): Rising Sophomore Rising Junior Rising Senior T-Shirt size (Please select one): S M L XL 2XL 3XL PARENT/GUARDIAN INFORMATION Name (Last, First MI): Address: City: State: Zip: Home Phone: Work Phone: Cell Phone: EMERGENCY CONTACT INFORMATION Name: Telephone: Home Phone: Work Phone: Cell Phone: MEDICAL INSURANCE INFORMATION Company: Telephone: Policy Number: Policy Holder s Name

3 STUDENT LEADERSHIP EXPERIENCE Please list three (3) to five (5) leadership experiences or positions that you have held: STUDENT SUMMARY OF INTENT Please use the space below or attach a typed document (200 to 225 word limit) detailing your interest in attending this conference. Questions to be considered for the summary include, but are not limited to: Why do you want to intend the Missouri Legislative Black Caucus Youth Leadership Conference? What do you hope to gain from the conference itself? How do you believe this conference will help you grow as a leader? What can you contribute to the conference?

4 PUBLIC INFORMATION RELEASE I, the natural parent(s) or legal guardian(s) of the student,, hereby give my consent and permission for my student to be on radio, photographed or videotaped for use in news stories/promotions about/for the Missouri Legislative Black Caucus Youth Leadership Conference. This consent applies only to the use of my student for non-profit, non-commercial purpose by the University of Missouri (MU) and Missouri Legislative Black Caucus Foundation, Inc. (MLBCF), news organizations or agencies representing MU/MLBCF. This contract is in effect until revoked in writing. RELEASE OF LIABILITY I, the natural parent(s) or legal guardian(s) of the student,, desire and consent for my student to attend and become officially enrolled in the Missouri Legislative Black Caucus Youth Leadership Conference. l release and discharge the Missouri Legislative Black Caucus Foundation Inc. and the University of Missouri, and its representative, employees and agents, form any and all claims, losses, demands, damages, cause of action, judgments or law suits of any kind which either l or my student may have arising out of or in connection with my student's participation and enrollment in the Missouri Legislative Black Caucus Youth Leadership Conference to be held at the University of Missouri. l do hereby agree to have and indemnify and keep harmless the Missouri Legislative Black Caucus Foundation, Inc. and the University of Missouri, its representatives, agents, and employees, against any and all liability, arising out of or in connection with my student s participation and enrollment in the Missouri Legislative Black Caucus Youth Leadership Conference.

5 CONSENT FOR STUDENT S PARTICIPATION I, the natural parent(s) or legal guardian(s) of the student,, understand that my student is applying to participate in the Missouri Legislative Black Caucus Foundation Youth Leadership Conference hosted jointly by University of Missouri (MU) and the Missouri Legislative Black Caucus Foundation, Inc. (MLBCF). I give my permission for the student to attend if accepted, and I understand and agree to the following regarding the student application: 1. The student will be at the Missouri Legislative Black Caucus Youth Leadership Conference, July 22-24, 2012, and supervised at all times by MU/MLBCF personnel. 2. Students traveling over five hours to the program will be allowed to stay the evening of July 24 and depart the morning of July 25. All MU/MLBCF program rules, policies, and procedures will apply during this extended time. These arrangements must be approved in advance by MU. 3. There is no cost to attend the Missouri Legislative Black Caucus Youth Leadership Conference. If a student is no longer able to participate, the MLBCF must be notified by July 6, 2012 to avoid a $25.00 cancellation fee. 4. The student will stay in a residence hall on the campus of MU during the program. Male and Female students will be housed in separate rooms and supervised by MU/MLBCF personnel. 5. The student, while at MU, will be taking learning about college and leadership. They will work with MU/MLBCF faculty, staff, and students. The student will also participate in local field trips. Transportation for field trips will be provided by MU/MLBCF. 6. The student must adhere to MU/MLBCF policies while on campus and while participating in all activities sponsored by the program. Failure to adhere to policies may result in dismissal from the program. 7. The parent/guardian will be contacted by MU/MLBCF staff should a situation arise that requires consultation. 8. I acknowledge that all risks cannot be prevented, and I assume those beyond control of MU/MLBCF staff. This signature of a parent/guardian is required for this application to be valid. The signature below indicates the information on the application form is accurate and truthful.

6 MEDICAL TREATMENT I, the natural parent(s) or legal guardian(s) of the student,, in the event of an emergency or medical treatment, hereby give my consent and/or authorization to the Missouri Legislative Black Caucus Foundation, Inc. and/or the University of Missouri representative/supervisors or agents to authorize the necessary medical services and/or medical treatment for my student. It is understood that this authorization is given in advance of any specific diagnosis, treatment or medical care required, and is to serve as specific consent to any and all such diagnosis, treatment or hospital care which may be deemed necessary. Medical services provided are approved for my student during their stay throughout the 2012 Missouri Legislative Black Caucus Youth Leadership Conference. I request that payment under my medical insurance be made directly to the medical facility or through my insurance program for any invoices for services rendered by a medical facility on behalf of my student. I understand that I am personally and financially responsible for all medical services provided for medical treatment, diagnosis or care of my student. I also release the Missouri Legislative Black Caucus Foundation and/or the University of Missouri and their agents and representatives of any financial or medical diagnosis, care or liability associated with the medical treatment of the student mentioned above. Please be aware of the following health needs of my student: