Be the Difference DMV

School Name

How many days will your school attend the event?

One Day: Oct 9 (mandatory)Both Days: Oct 9 and Nov 6

Number of Students Registering (minimum 10).*

10 Students20 Students30 StudentsOther

I understand my school must complete a roster with student information in the event of an emergency.

YesNo

I understand that my school is required to provide chaperones (staff/parents) at a ratio of 1 to 10 students. All chaperones must have a valid background check completed that dates no greater than 365 days.*

YesNo

I understand that my students are responsible for providing their own lunch and water bottle.*

YesNo

I understand that my school is responsible for providing any medical supplies needed for our students (ex: inhalers, epi-pens, medications etc)*

YesNo

I understand that by submitting this form it is a binding contract and will beheld liable for the cost of student attendance whether our school/students are in attendance or not.*

I agree

School Billing Contact*

First NameLast Name

Phone Number*

Area CodePhone Number

Email*

example@example.com

Release:

Participants in any Break the Norm Leadership activities and use of any recreational facilities involves a risk for accident or injury despite all safety precautions. Having been informed of the activities to be conducted by Break the Norm Leadership, I/We as individuals or as a parent or guardian, or school of the participants named herein, assume all risks and hazards incidental to the activities and release responsibility and agree to indemnify, and hold harmless(including the payment of attorney’s fee) Break the Norm Leadership its officers, directors, independent contractors, volunteers, and all employees for any illness, death or injury to me, or my child, or family members, occurring during his/her our participants in any activities or use of recreational facilities at or conducted by Break the Norm Leadership.

Permission to photograph or video. I give permission for BTNL to use my child’s image in any future club material should it appear in photos or videos taken during this event.

School Employee Signature*

School Employee Name*

First NameLast Name

Phone Number*

Area CodePhone Number

Email*

example@example.com

Be the Difference (DC, MD, VA

Invoicing