2024 Leadership Institute - Registration Form (3 of 3)

2024 Leadership Institute Registration Form

(Does not include Symposium Registration) Leadership Institute: October 28-29, 2024
Note: Registrations submitted after October 4, will receive a modified name badge.
Attendee's Name*

First NameLast Name
Attendee's Organization *
Attendee's Job Title *
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Attendee's Email Address *

Confirmation EmailConfirm email
Attendee's Phone Number:*
Job Categories: (Please select a category below that best corresponds with your current job status) *
Are you a:*

Senior Level LeadershipMid Level ManagerDirect Care StaffOther
If you're a supervisor, how many direct reports are under your supervision? *
Do you consider yourself a:*

Veteran Leader (5+ years of experience and comfortable leading people)Emerging Leader (Less than 5 years of experience and/or still not comfortable leading people)Other
Pre-Symposium Tours: The tours have reached full capacity, and registration for the tours is now closed. Thank you for your interest!
Dietary Restrictions:

VegetarianVeganGluten FreeKosherNut AllergyOther
Other/Additional Details:
ADA: Pursuant to the Americans with Disabilities Act, do you require specific aids or services?

AudioVisualMobileOther
Additional Details:
Emergency Contact *

First NameLast Name
Phone Number*
Please enter a valid phone number.
How did you hear about the Leadership Institute?

Attended a previous NPJS SymposiumLinkedInNPJS Discipline GroupNPJS EblastsNPJS MemberNPJS Social MediaNPJS WebsiteOJJDP JuvJust ListServReferral from Friend/ColleagueYouth Today Social MediaOther
Registration Terms

NPJS reserves the right to cancel any session, at any time.

NPJS or its contractors may photograph or videotape sessions and events at the conference. By attending the conference, attendees understand and agree to allow their images to be used by NPJS in its publications, on its website, and in marketing or promotional materials. Photo images may also be shared with the media. Attendance at the meeting waives NPJS from liability resulting from these uses.

NPJS may share your registration information with its sponsors and vendors. By registering for the conference, you agree to allow this information to be shared and understand that you may be contacted by our vendors.

Any and all liability of the National Partnership for Juvenile Services (NPJS) with respect to attendance, registration, reservations, cancelations, changes in the location or content of the program, and refunds is limited to a sum no greater than the registration fee paid. Under no circumstances shall NPJS be liable for incidental or consequential damages of any kind, including, but not limited to, the cost of transportation or lodging. Conference attendee waives all claims of any kind against NPJS and its respective employees and agents arising from their participation in the conference. The attendee further agrees to defend, indemnify, and hold harmless NPJS and its respective employees and agents from any and all damages, claims, or other liabilities resulting from any act or omission connected with attendee’s participation in the conference, whether negligent or not. The attendee’s liability shall include all losses, costs, damages, or expenses arising from or out of or by reason of any accident or bodily injury or other occurrences which result from or out of the attendee’s participation in the conference. Attendees agree to adhere to all health and safety requirements mandated by hotel and local/state jurisdictions.

Submission of registration and payment constitutes acceptance of the terms and conditions herein.
Terms and Conditions*

I Agree
Order Summary / Receipt: Please provide additional contact information if you wish for your administrator or accounting department to receive a confirmation email as well. This ensures that all relevant parties are informed about your registration.

First NameLast Name
Email Address (Administrator /Accounting Department):
example@example.com
Payment (Select a payment option):*

Credit CardPO/Invoice (If applicable, enter PO Number Below and NPJS will send you an invoice)
PO Number:
REGISTRATION INVOICE: Leadership Institute ONLY: (Does NOT include Symposium Registration)

NPJS Member or Host State - $249Non-Member - $324Student Registration - $99 (A limited number of Student Scholarship are available for full time students, please email Michael.Jones@npjs.org if interested)Donation to Support Student Scholarship Fund - $50 (In an effort to build interest in the field of Juvenile Justice, NPJS is inviting students to attend our Symposium. We need your help to sponsor student attendance. For alternative donation amounts, please reach out to Michael Jones at michael.jones@npjs.org)NPJS Membership Dues - $35.00 (For more information about NPJS Membership, visit: https://www.npjs.org/membership)
CREDIT CARD (Leadership Institute Rates):
prevnext( X )
NPJS Member or Host State Leadership Institute ONLY (Does NOT include Symposium Registration)
$249.00



Non-Member Leadership Institute ONLY (Does NOT include Symposium Registration)
$324.00



Student Registration Leadership Institute ONLY (A limited number of Student Scholarship are available for full time students, please email Michael.Jones@npjs.org if interested).
$99.00



Pre-Symposium Tour - Decker Lake Youth Center (Secure Care Facility)Monday, October 28, 2024 - 9:00am - 11:30am
$30.00



Donation to Support Student Scholarship FundIn an effort to build interest in the field of Juvenile Justice, NPJS is inviting students to attend our Symposium. We need your help to sponsor student attendance. For alternative donation amounts, please reach out to Michael Jones at michael.jones@npjs.org.
$50.00



NPJS Membership DuesFor more information about NPJS Membership, visit: www.npjs. org/membership
$35.00



Total

$0.00

Should be Empty:

2024 Leadership Institute Registration Form