New England Student Leadership Conference
July 16-19, 2019

 Worcester State University – Worcester, MA


Adult Delegate and Adult/College Facilitator Application


To submit an application to participate in the 2019 New England Student Leadership Conference, please complete the online application found at the link below. Contact information for each participating state association can be found in the conference information packet (CLICK HERE). 


When you are ready to apply, please click “Next” below!

Are you an Adult Delegate or Facilitator?*
Which association are you from?*
Name*
Home Address*
Based on men's sizing


Emergency Contact*
School Principal*

Terms & Conditions


If selected, I agree to attend the New England Student Leadership Conference, July 16-19, 2019.

By checking this box, you are agreeing to the terms and conditions as stated above.*
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Date*

Name*
Date of Birth*
Home Address*


Emergency Contact*
Do you have any special physical needs?*
Do you have any special dietary needs and/or food allergies?*
Do you have any life threatening allergies?*
Are you allergic to any medications? (penicillin, antibiotics, pain medications, etc.):*
Do you carry an Epi-Pen?*
Are you allergic to bee stings?*
Can you take Antihistamines?*
Can you take Ibuprofen?*
Can you take Acetaminophen (Tylenol)?*

Please type N/A if there are none to report.

By checking this box, you are agreeing to the accuracy of the information stated above.*
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I, the undersigned adult leader, do hereby agree:

  • 1.To abide by all the rules and regulations set forth by the sponsoring state associations and all adult supervisors.
  • 2.To waive and release any and all rights and claims for any damages I may have against the sponsoring state associations, and any other employee of the state associations, for any injuries arising from my participation in this activity.
  • 3.To accept responsibility for my behavior so that it does not reflect discredit on my school, my state association, or myself.
  • 4.To use no tobacco, alcohol or illegal drugs at the conference.
  • 5.To treat all student and adult delegates, college and adult facilitators, conference staff, state association staff, speakers, and host site staff with respect and dignity.

I understand that if I break any of the rules of the conference that I will be sent home immediately at my own expense.

By checking this box, you are agreeing to the terms and conditions as stated above.*
Name*
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Date*

(the “Agreement”) For the New England Student Leadership Conference, July 16-19, 2019 (the “Conference”)


In consideration for being permitted to observe, work for, or for any purpose participate in any way in the New England Student Leadership Conference, each of the undersigned, for him or herself, his/her personal representatives, heirs, next of kin, acknowledges and agrees and represents that he/she agrees to:


Consent to the undersigned’s participation in the New England Student Leadership Conference, a voluntary activity, and do forever RELEASE, acquit, discharge, and covenant to hold harmless the participating state associations, any and all sponsors of the Conference, their subsidiaries, parents, affiliates, officers, directors, agents and representatives, Conference promoters, participants, venue operators and owners, city officials, competitors, technicians, and any persons in any restricted area, lessees of the premises used to conduct the Conference, collectively referred to “releasees” from any and all actions, causes of action and claims on account of, or in any way growing out of, directly or indirectly, all known and unknown personal injuries or property damage which I may now or hereafter have or may hereafter may acquire, resulting from his/her participation in the Conference. 


AGREE TO INDEMNIFY AND SAVE AND HOLD HARMLESS the releasees and each of them from any loss, liability, damage, or cost they may incur due to the presence of the undersigned in or upon the restricted areas or in any way competing, officiating, observing, or working for, or for any purpose participating in the Conference and whether caused by the negligence of the releasees or otherwise.


ASSUME FULL RESPONSIBILITY FOR ANY RISK OF BODILY INJURY, DEATH OR PROPERTY DAMAGE due to the negligence of releasees or otherwise while in or upon restricted areas and/or while participating, observing, working for, or for any purpose participating in the Conference. THE UNDERSIGNED EXPRESSLY ACKNOWLEDGES AND AGREES THAT THE ACTIVITIES OF THE Conference are dangerous and involve the risk of serious injury and/or property damage. THE UNDERSIGNED further expressly agrees that the foregoing release, waiver, and indemnity agreement portion thereof is intended to be as broad and inclusive as is permitted and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.


THE UNDERSIGNED hereby grants permission to the participating state associations full permission now and forever, with no obligation to compensate me further, to use photographs, videotapes, motion pictures, recordings, or other record of my participation for advertising and promotional materials and for any other purpose the participating state associations, in its sole discretion deems necessary. This includes the posting of such photographs, recordings, or other media representation of myself, on any website, or licensing others to do so in their promotional materials or websites.


I affirm that I have read this Release and Waiver of Liability and Indemnity Agreement and that I understand the contents of this form. I understand that my participation in this Conference is voluntary and I am free to choose not to participate in said Conference. By signing this form, I affirm participation in the Conference with full knowledge that the releasees will not be liable for personal injuries and property damage that I may suffer in voluntary participation in the Conference.


NOTICE: BY SIGNING THIS RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT, RELEASEOR IS AGREEING TO HAVE ANY CLAIM DECIDED BY NEUTRAL ARBITRATION AND IS GIVING UP THE RIGHT TO A JURY OR COURT TRIAL. THE UNDERSIGNED HAS READ AND VOLUNTARILY SIGNS THE RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT, and further agrees that no oral representation, statements or inducements apart from the foregoing written agreement have been made.

By checking this box, you are agreeing to the terms and conditions as stated above.*
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