Reunion Registration Form

2021 FALL REUNION REGISTRATION

October 16-17th, 2021
COVID-19 (Coronavirus) Update

Masks will be required at reunion.
AS YOU CAN SEE - IT'S ONE FORM!!!

Please have insurance card, parent (if you are under 19), and about 5-10 minutes to fill out the form! Jotform offers HIPAA compliance - Your health information is stored in secured servers and is highly encrypted. All precautions will be taken to keep this data safe.
The wait is FINALLY OVER! NLS FALL REUNION!

We can't wait to see you in Pleasanton for Fall Reunion on October 16-17th!

You must complete this to be officially registered for the 2021 NLS Summer Reunion at Pleasanton Public Schools from 12pm on October 16th to 12pm on October 17th. If you have any questions or concerns, please email Sophie at alumni@nebraskaleadership.org

ADDRESS OF SCHOOL: 303 W Church Street Pleasanton, NE 68866

Registration is $20 until October 9th; thereafter, the cost is $30.

PLEASE send us an email if cost is a barrier! We want to see you!

We accept cash, check, or VENMO!
Basic Information
Name *

First Name Last Name
Gender *
Male, Female, Gender Non-Binary, etc.
Pronouns *

He/Him/His She/Her/Hers They/Them/Their Ze/Zie/Hir
High School *
College (if applicable)
Current Work (if applicable)
Year you attended Seminar *

2021/Milford 2019/Milford 2018/Milford 2017/Midland 2016/Midland 2015/Midland 2014/Midland 2013/Doane 2012/Doane 2011/Doane 2010/Doane
Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Your Email *
example@example.com
Parent Email *
example@example.com
Your Phone Number *

Area Code Phone Number
Parent Phone Number *

Area Code Phone Number
Will you be arriving late? *

Yes No Maybe
If you are arriving late, what time will you arrive. We will contact you as to where we will be.

: Hour Minutes AM/PM Option
If you are leaving early, what time will you be leaving?

: Hour Minutes AM/PM Option
Any dietary needs or allergies we need to be made aware of? *
How old will you be on October 16th, 2021? *
Any Snack Requests?
Not guaranteed, but we will try to mix things up!
What kind of pizza would you be interested in eating? Please mark a max of two! If you would be interested in two different toppings, put in in the bottom box and we will see if there is a large interest! *

Pepperoni Sausage Meatball Ham Bacon Grilled Chicken Beef Pork Cheese I am lactose intolerant or have an allergy!
Emergency Contact
Name *

First Name Last Name
Relationship *
Phone Number *

Area Code Phone Number
Alternate Phone Number

Area Code Phone Number
Medical History

HIPAA COMPLIANT - YOUR INFORMATION IS PROTECTED
Alumni Date of Birth *

Month Day Year
Date
City of Birth *
City, State
Name of Family Physician *
Physician Phone Number *

Area Code Phone Number
Disabilities
Allergies
Special Needs
Does the alumni have health insurance? *

Yes No
Health Insurance Provider *
Examples include BlueCross/BlueShield, UMR, United Health, Aetna, Humana, etc. This is not the place of employment of yourself or your parents.
Health Insurance Provider Member ID, Group Number, etc. *
If you are not sure what number to put down, please put down all numbers on the card, separated by commas. The Alumni Association will contact you if the number is not included in the correct format.
Medical Conditions *

NONE Asthma Vision Loss Stomach Ulcers Ear Infection Convulsions Chicken Pox Hay Feaver / Allergies Dizzy Spells Mononucleosis Migraines Fainting Spells Mumps Nose Bleeds Difficulty Sleeping Pneumonia Measles Epilepsy Tonsillitis Hearing Loss Diabetes
What treatments or medications (if any) do you require for any of the above conditions?
Please list the name of any medication you are taking, the dosage, and the condition that requires you to take the medication:
Are there any past hospitalizations or other illnesses we should be aware of?
In consideration of the rights to attend and participate in the Activities described above, the Participant is under 19 years of age, his or her parent or legal guardian) hereby:

1. Agrees to abide by all rules and regulations established by Nebraska Leadership Seminar Inc (NLS).

2. Authorizes NLS or any of its agents to provide, obtain, or authorize any reasonable incidental and/or emergency medical treatment for the Participant, in the event of the Participant’s illness, injury, or incapacity, and hereby accepts the responsibility to pay for such treatment.

3. Grants for NLS for any purpose connected with promoting the purpose and goals of NLS, but not for commercial exploitation, the right to use the Participant’s name, voice and likeliness in any writings, photographs, films, and recordings of the Participant while he or she is participating in the Activities, and any biographical information submitted by the Participant to NLS, and to use, reproduce, publish and distribute the same.

4. Acknowledges that there is an element of risk involved in any activity involving travel outside of one’s own home or community; certifies that the Participant is physically, mentally, and emotionally capable of attending and participating in the Activities; assumes all risk of and financial responsibility for any loss or injury to the Participant or others that may occur as a result of the Participant’s negligence or misconduct; and indemnifies and holds NLS harmless from and against any and all
costs, claims, demands, charges, liabilities, obligations, judgments, executions, cost of the suit and actual attorney’s fees incurred or suffered by NLS as a result of, or arising out of, the Participant’s negligence or misconduct.

This Consent and Acknowledgement of Risk shall not be amended, supplemented, or abrogated without the written consent of NLS. The Participant (and, if the participant is under 19 years of age, his or her parent or legal guardian) has read this Consent and Acknowledgment of Risk, and understands its consents.
Alumni Release - Consent and Acknowledgement of Risk

Please read prior to signing
Alumni Signature *

Clear
DO NOT FORGE - Parent Signature (If alumni is under the age of 19). Please put an X if alumni is over the age of 19. *

Clear
Please verify that you are human *
Should be Empty:

2021 FALL REUNION REGISTRATION

COVID-19 (Coronavirus) Update

AS YOU CAN SEE - IT'S ONE FORM!!!

Basic Information

Emergency Contact

Medical History

Alumni Release - Consent and Acknowledgement of Risk