2023-24 PLC Registration Form

2023-24 Poetry & Leadership Conference Registration Form
Saturday, December 16, 2023 • 8:30am to 3:30pm
Check-in begins at 7:45am ET
Registrant Information
Name of Registrant*

First NameLast Name
Name of School, Company or Organization*
Registration Type*

StudentEducatorStakeholderOther
Grade (if applicable)*
Name of Poetry Club Sponsor/Coach*
If you have none or are unsure, enter N/A.
Email Address of Club Sponsor/Coach*
If you have none or are unsure, enter your own.
T-shirt Size*
All shirts are adult unisex sizes.
Meal Preference*
All shirts are adult unisex sizes.
Registrant Mobile Phone*
Registrant E-mail Address*
example@example.com
Twitter Profile (if applicable)
Instagram Profile (if applicable)
Facebook Profile (if applicable)
Registrant Home Address

Street Address

Street Address Line 2

CityState

Zip Code

Parent/Guardian Information

For Student Registrants Only
Name of Parent/Guardian*

First NameLast Name
Parent E-mail Address*
example@example.com
Parent Mobile Phone*
Emergency Contact Name*
Emergency Contact Mobile Phone*
Special Needs / Health Conditions / Food Allergies
Please list any and all information we should know regarding the health and/or needs of your child.

2023-24 PLC & LTABFLA Waiver & Release Form

TO BE COMPLETED ONLY BY PARENT OR GUARDIAN
MEDICAL WAIVER: I HEREBY GIVE CONSENT to the Jason Taylor Foundation / Omari Hardwick bluapple Poetry Network to provide professional medical attention, customary medical/athletic training attention, transportation, and emergency medical services as warranted in the course of my child’s participation in the 2023-24 Omari Hardwick bluapple Poetry Network’s 11th Annual Poetry & Leadership Conference (PLC) AND 2023 Louder Than A Bomb Florida (LTABLFA) Poetry Festival.

WAIVER & RELEASE OF LIABILITY (PLEASE READ CAREFULLY): I HEREBY ACKNOWLEDGE, APPRECIATE, and COMPREHEND THAT THE ACTIVITIES AND EVENTS OF THE 2023-24 PLC and LTABFLA INVOLVE THE RISK OF SERIOUS INJURY, PARALYSIS, AND EVEN DEATH, as well as other damages and losses.

BEING FULLY COGNIZANT AND AWARE OF THESE RISKS I AGREE TO ASSUME ALL RISKS of my child’s involvement in the 2023-24 PLC and LTABFLA and further agree to RELEASE, INDEMNIFY, and HOLD HARMLESS the Jason Taylor Foundation, Omari Hardwick bluapple Poetry Network as well as Jason Taylor, or Omari Hardwick individually, along with all employees, agents, officers, directors, owners and sponsors of the Jason Taylor Foundation/Omari Hardwick bluapple Poetry Network FROM ANY LOSSES, LIABILITIES, INJURIES, or DAMAGES occurring to my child, any other person, or property, as a result of my child’s participation in the 2023-24 PLC and LTABFLA or as a result of the negligence of the Jason Taylor Foundation, Omari Hardwick bluapple Poetry Network, Jason Taylor, Omari Hardwick and any and all employees, agents, officers, directors, owners, and sponsors of the Jason Taylor Foundation or the Omari Hardwick bluapple Poetry Network. I also covenant not to bring any legal action should any loss, injury, or damage occur to my child, another person, or property as a result of my child’s participation or as a result of negligence.

I AM AWARE THAT THIS CONTRACT IS LEGALLY BINDING AND THAT I AM RELEASING LEGAL RIGHTS BY SIGNING IT AND THAT THIS AGREEMENT CONTAINS THE ENTIRE AGREEMENT BETWEEN THE PARTIES.
Primary Medical Insurance Carrier:*
If student has no primary medical insurance carrier, please enter "N/A".
Name of Parent or Legal Guardian*

First NameLast Name
By signing below, I give consent for my child, *

First NameLast Name
to participate in the 2023-24 Omari Hardwick bluapple Poetry Network’s 12th Annual Poetry & Leadership Conference AND in the 2024 Louder Than A Bomb Florida Poetry Festival, and agree to the Terms and Conditions of this Waiver & Release form.
Signature of Parent or Legal Guardian*

Clear
Date*

MonthDayYear
Date

2023-24 PLC & LTABFLA Photographic Release

TO BE COMPLETED ONLY BY PARENT OR GUARDIAN
For good and valuable consideration, the sufficiency and receipt of which is hereby acknowledged, I,
Name of Parent or Legal Guardian*

First NameLast Name
as the parent or legal guardian of
Name of Student*

Student's First NameStudent's Last Name
who currently attends
Name of School*
do hereby grant to the Jason Taylor Foundation and Omari Hardwick bluapple Poetry Network and to their licensees, assignees and successors-in-interest the unlimited right to utilize, reproduce and/or edit photographs at its sole discretion, likenesses or the voice of my child in perpetuity any legal manner for the internal or external promotional/informational activities of the Jason Taylor Foundation and Omari Hardwick bluapple Poetry Network, including, but not limited to the Jason Taylor Foundation and Omari Hardwick bluapple Poetry websites and social media sites (including Facebook, Twitter, YouTube, etc.).

I also agree to allow my child to be interviewed and/or photographed by representatives of the external news media in relation to any and all coverage of the Jason Taylor Foundation and Omari Hardwick bluapple Poetry Network in which they are involved.

I further understand that by signing this release, I waive any and all present or future compensation rights to use the above stated material(s).
Signature of Parent or Legal Guardian*

Clear
Date*

MonthDayYear
Date
Address of Signing Parent or Legal Guardian*

Street Address

Street Address Line 2

CityState

Zip Code

Be sure to download this tentative conference agenda for planning purposes

Workshop Selections

Please note that workshop selections are based on a first come, first served basis.
Session #1 Workshop Selection

Choose your top three workshop choices based on the workshop descriptions above.
*** You cannot select the same workshop in more than one drop down. ***
Be sure to select three (3) different workshop options for each session.
Select your FIRST choice of workshop for Session #1*
Workshops have limited space and will be assigned on a first come, first served basis.
SESSION 1.2 CALCULATION
Select your SECOND choice of workshop for Session #1*
Workshops have limited space and will be assigned on a first come, first served basis.
Select your THIRD choice of workshop for Session #1*
Workshops have limited space and will be assigned on a first come, first served basis.
SESSION 1.3 CALCULATION
Session #2 Workshop Selection

Choose your top three workshop choices based on the workshop descriptions above.
*** You cannot select the same workshop in more than one drop down. ***
Be sure to select three (3) different workshop options for each session.
Select your FIRST choice of workshop for Session #2*
Workshops have limited space and will be assigned on a first come, first served basis.
SESSION 2.1 CALCULATION
Select your SECOND choice of workshop for Session #2*
Workshops have limited space and will be assigned on a first come, first served basis.
SESSION 2.2 CALCULATION
Select your THIRD choice of workshop for Session #2*
Workshops have limited space and will be assigned on a first come, first served basis.
SESSION 2.3 CALCULATION
Session #3 Workshop Selection

Choose your top three workshop choices based on the workshop descriptions above.
*** You cannot select the same workshop in more than one drop down. ***
Be sure to select three (3) different workshop options for each session.
Select your FIRST choice of workshop for Session #3*
Workshops have limited space and will be assigned on a first come, first served basis.
SESSION 3.1 CALCULATION
Select your SECOND choice of workshop for Session #3*
Workshops have limited space and will be assigned on a first come, first served basis.
SESSION 3.2 CALCULATION
Select your THIRD choice of workshop for Session #3*
Workshops have limited space and will be assigned on a first come, first served basis.
SESSION 3.3 CALCULATION

SESSION 1.1 CALCULATION
Thank you for your registration!
Should be Empty:

2023-24 Poetry & Leadership Conference Registration Form

Registrant Information

Parent/Guardian Information

2023-24 PLC & LTABFLA Waiver & Release Form

2023-24 PLC & LTABFLA Photographic Release

Workshop Selections

Session #1 Workshop Selection

Session #2 Workshop Selection

Session #3 Workshop Selection

Thank you for your registration!