NWGA Youth Conference
Mentor-guide registration form for the NWGA Conference.
Mentor-Guides impact the conference participants in a very special way. The conference participants are divided into groups of twenty-five and the mentor-guides lead the small groups throughout the conference schedule. Mentor-guides have found this to be a very motivating and impactful role as they get to interact with the students throughout the whole event.
Name
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First Name
Last Name
Email Address
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Gender
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Female
Male
Non-Binary
Other
Race/Ethnicity. (If more than one apply, please select "Other" below and type your selection in the open box.)
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Latino/Hispanic
White/Caucasian
African American/Black
Asian
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Other
Cell Phone Number
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Area Code
Phone Number
All mentor-guides must attend one mandatory training session prior to the event.
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I agree to attend the training
What is the name of your college, university or Company?
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If you are participating on behalf of a student/corporate organization or fraternity/sorority, please let us know the name of your org:
Are you a student, faculty, staff member or professional?
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Student
University Faculty/Staff
Recent Graduate
Working Professional
Other
What is your level of education?
Please Select
Freshman
Sophomore
Junior
Senior
Undergrad Degree Completed
Grad Degree Completed
Do you require a vegan meal option?
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Please Select
Yes
No
Please provide your t-shirt size.
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Please Select
Small
Medium
Large
XL
Is this your first Conference?
Please Select
YES
NO
If "NO", please tell me how many you have attended in the past.
Are you bilingual? (Spanish/English) This is not a requirement to participate.
Yes
No
RELEASE OF LIABILITY, COVENANT NOT TO SUE AND ASSUMPTION OF RISK. I have volunteered to participate in THE LATINO YOUTH LEADERSHIP CONFERENCE through Dalton State College ON MARCH 16, 2023 (the “Program”). I acknowledge that I am covered by an accident and health insurance policy and am physically and mentally capable of participating in the Program. I understand that Releases (as defined below) do not guarantee the competency or mental or physical condition of any person associated with the Program, the physical condition of any facility or equipment used in connection with the Program, or the suitability of the Program for my participation. I understand that there are inherent risks involved in participating in the Program, and I realize that participation in the Program is my choice. I am aware that, during the Program, certain risks and dangers may occur, including, but not limited to, the hazards of traveling by automobile, van, ride sharing services like Uber, taxi, bus, rail or other conveyance; the hazards of large groups of people; accident or illness; the forces of nature; all manner of foreseen and unforeseen bodily and personal injuries, including death; damage to property; and the consequences resulting there from. I understand that it is my responsibility to know what personal equipment is required (such as footwear and clothing) and provide the proper personal equipment for my participation in the Program, and to ensure that it is in good and suitable condition. I agree to ask questions to make sure that I know how to safely participate in the Program.IN CONSIDERATION OF BEING PERMITTED TO ATTEND AND PARTICIPATE IN THE PROGRAM, I ACKNOWLEDGE AND VOLUNTARILY ASSUME ALL RISKS OF DAMAGES OR INJURY, INCLUDING DEATH, THAT I MAY SUSTAIN OR THAT MY PROPERTY MAY SUSTAIN WHILE I PARTICIPATE IN THE PROGRAM, ALONG WITH ANY TRAVEL TO OR FROM SUCH ACTIVITY OR THE PROVISION OF TRANSPORTATION TO OR FROM THE PROGRAM. In addition, I, on my own behalf and on behalf of my heirs, representatives, executors, administrators and assigns, for the sole consideration of being allowed to attend and participate in the Program, do hereby release, relieve, covenant not to sue and forever discharge, defend, indemnify and hold harmless, Dalton State College, and its trustees, directors, officers, agents, employees, students, members and volunteers, , as applicable, (hereinafter collectively "Releases") of any and from all claims, demands, rights, liabilities, losses, expenses, and causes of action (with the exception of gross negligence or willful misconduct) of whatever kind or nature including, but not limited to, negligence, arising from and by reason of any and all known and unknown, foreseen and unforeseen bodily and personal injuries, damage to property, and the consequences thereof, including death, resulting from any participation in or in any way connected with arising out of or connected with the Program, including any claim arising out of or connected with any illness or injury (minimal, serious, catastrophic and/or death) that I may incur or sustain during the Program, all activities associated with the Program and while traveling to and from the site for the Program whether or not events during the Program actually occurs. I HEREBY WARRANT THAT I HAVE READ THIS RELEASE OF LIABILITY, COVENANT NOT TO SUE AND ASSUMPTION OF RISK (“RELEASE” OR “RELEASE OF LIABILITY”) IN ITS ENTIRETY AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT THIS RELEASE OF LIABILITY RELEASES RELEASEES FROM LIABILITY AND CONTAINS AN ACKNOWLEDGEMENT OF MY VOLUNTARY AND KNOWING ASSUMPTION OF THE RISK OF INJURY OR ILLNESS.
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MEDIA RELEASE: For good and valuable consideration herein acknowledged as received, I hereby grant to Releasees, and those acting with Releasees’ authority and permission, the irrevocable and unrestricted right and permission to create, use, re-use, publish and re-publish video recordings, audio recordings, photographs, or other media that contain or capture my likeness or voice or in which my likeness or voice may be included (the “Recordings”) in connection with any publication or materials relating to or serving the mission and goals of Releasees’, including advertisements, brochures, or other promotional materials. The Recordings may be used with or without my name, and in any and all media now or hereafter known. I acknowledge and agree that Releasees’ own all right, title, and interest in and to the Recordings, including all copyrights therein and the full and unrestricted right to edit and modify the Recordings, and I hereby assign and agree to assign any such interest that I may own or control to Releasees. I also consent to the use of any printed matter in conjunction with the Recordings. I hereby waive any right I may have to inspect or approve the Recordings or any finished product or products incorporating the Recordings and any written or other print material that may be used in connection therewith, including print material containing my name. I acknowledge that nothing in this Agreement obligates Releasees or any third party to make any use of the Recordings.
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BY SIGNING BELOW, I HEREBY ACKNOWLEDGE THAT I HAVE CAREFULLY READ AND UNDERSTOOD THE ABOVE BEFORE SIGNING AND AGREE TO COMPLY WITH THE ABOVE PROVISIONS. I INTEND THIS TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW AND AGREE THAT, IF ANY PORTION OF THE RELEASE IS HELD TO BE INVALID, THE BALANCE, NOTWITHSTANDING, SHALL CONTINUE IN FULL FORCE AND EFFECT. I expressly agree that this Release shall be governed by and interpreted in accordance with the laws of the State of Georgia without regard to conflict of law principles.
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First Name
Last Name
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Date
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Month
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Day
Year
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By completing the registration form:
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I acknowledge that I MUST attend a training session prior to the event
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