2024 DELEGATE LYS Medical/Media Release Form

Student Information
Student Name*

First NameLast Name
Student's School*
Attendance is limited to 14 per school. We will notify you after you register if your school has reached that maximum and place you on our waitlist automatically.
Student's Sex*

FemaleMale
Student Grade for '24/25 school year*
Student Email*
Confirmation of completed form and important student information will be sent to this address.
Student Phone Number*

Area CodePhone Number
Student Street Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student T-Shirt Size*
Student Ethnicity*
Has the student attended LYS before?*

YesNo
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Email *
Confirmation of completed form will be sent to this email. This is also primary contact who will get communications from LYS.
Parent/Guardian Phone Number*

Area CodePhone Number

Recruiter Information

How did you hear about LYS?
Recruiter Name

First NameLast Name
Recruiter's Email
example@example.com
Recruiter's Phone Number

Area CodePhone Number

Media Release
I agree that the name, voice, likeness, image and/or work of Student First Name* Student Last Name* may be used for publicity and/or informational purposes

by LYS and/or by members of the media as permitted by LYS.

LYS Delegate Code of Conduct

This basic code of conduct is designed to support, not stifle LYS student attendees (otherwise known as delegates of the program). We hope it will help provide delegates with a program they are proud to attend in an atmosphere where they have freedom to learn.
A virtual or downloadable version of this file is available at www.louisianayouthseminar.org/code
1. Delegates are expected to be active participants in all aspects of the program and to cooperate with all Louisiana Youth Seminar staff, fellow delegates, or guests and Louisiana State University personnel as requested.
  1. Delegates shall travel in their home groups and may not leave the group or assigned area without explicit permission from his or her counselor. Delegates must be accompanied, as a group or individual, at all times by a staff member or LYS official.
  2. Delegates are to abide by the outlined tech-friendly policies.
  3. Curfew will be set each night by the Program Director and shall be obeyed. Delegates are to remain in their assigned rooms after curfew.
2. Delegates shall conduct themselves in a respectful and courteous manner.
  1. The seminar is informal, but delegates must wear shoes and appropriate clothing at all times.
  2. Disrespect, harassment or repeated lack of cooperation with Louisiana Youth Seminar staff, fellow delegates, or guests will not be tolerated.
  3. Inappropriate language or behavior will not be tolerated. Intentional or repeated use of abusive language or profanity will not be allowed as any part of the program. This includes, but is not limited to presentations, cheers, skits, songs, speeches, group time, banners, caucus, dances, etc.
  4. No delegate shall harass or disrespect another delegate because of their personal or political beliefs, religious practices, ethnicity, race, or way of life.
  5. Sexual harassment of any individual will not be tolerated.
3. State laws and campus policies are to be obeyed.
  1. The use of tobacco products, alcohol and/or illegal drugs is prohibited.
  2. Hazing or abuse is prohibited.
  3. Intentional destruction or vandalism to Louisiana Youth Seminar or Louisiana State University property will not only result in dismissal from the program, but could require restitution or prosecution for such damages.
4. Leadership is to be exemplified by all LYS delegates.
  1. Delegates are expected to report any infraction of these rules to their home group or session leaders. Staff must then report the infraction to the Program Director or Assistant Program Directors.
  2. Any infraction to the rules or regulations outlined by the staff will be dealt with immediately by the Directors of the Seminar. Delegates will be informed of the infraction and consequence, which shall be at the discretion of the Program Director.
  3. Those delegates responsible for acts that are considered to be serious infractions will be immediately withdrawn from the delegate roster and sent directly home with all resulting charges and costs assessed to the particular delegate. In addition, a letter will be sent to the delegate's high school principal (and sponsor if appropriate).

In Case of Emergency Contact Person
Emergency Contact Name*

First NameLast Name
Emergency contact Relation*
Contact's relationship to student
Emergency Contact Cell Phone Number*

Area CodePhone Number
Emergency Contact Alternate Phone Number

Area CodePhone Number
Alternate Emergency Contact (If initial contact cannot be reached)*

First NameLast Name
Alternate Emergency Contact Phone Number*

Area CodePhone Number

Insurance Information

Please share student insurance information and upload a clear photo or scan of both sides of the student's medical insurance card
Insurance Carrier Name*
Policy Number*
Insurance Card

Upload Insurance Card Here

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Covid-19 Waiver and Assumption of Risk
In consideration of being allowed to participate in the Louisiana Youth Seminar on premises of Louisiana State University (the “Seminar”), the below signed participant, and the participant’s parent(s) or legal guardian(s) if the participant is a minor, agrees as follows:

1.     I am aware that the novel coronavirus (“COVID-19”) is an extremely contagious virus and that it is currently believed that COVID-19 spreads through person-to-person contact.

2.     I am familiar with the Center for Disease Control and Prevention (”CDC”) guidelines regarding COVID-19, which are located at https://www.coronavirus.gov and https://www.cdc.gov/coronavirus/2019-ncov/index.html. I acknowledge and understand that the circumstances regarding COVID-19 are changing from day-to-day, and that the CDC guidelines are regularly modified and updated. I accept full responsibility for familiarizing myself with the most recent updates, and making informed choices to take precautionary measures to protect myself and others.

3.     In addition to the CDC guidelines, I agree to abide by any and all policies or postings published to delegates, staff, or the general public at the Seminar.

4.     By signing this agreement, I acknowledge that I am aware of the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 at the Seminar, and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at the Seminar may result from the actions, omissions, or negligence of myself and others.

5.     I agree that, in the event that I suspect I became exposed to or infected by COVID-19 at the Seminar and I elect to seek testing and/or treatment as a result therefrom, I will be responsible for payment of any and all medical services and testing services.

I voluntarily choose to assume all of the foregoing risks and accept sole responsibility for any injury, illness, permanent disability, or death related to COVID-19 arising from or in connection with my presence at the Seminar. I hereby release and hold harmless the Seminar, its employees, volunteers, staff, agents, directors, officers and representatives and other participants ("Released Parties") from and against all liabilities (statutory or otherwise) for claims, suits, demands, judgments, costs, interest and expense (including but not limited to attorney’s fees and disbursements) for injury, illness, permanent disability, or death related to COVID-19 arising from or in connection with my child(ren)’s presence at the Seminar, EVEN IF ARISING FROM THE NEGLIGENCE, ACTS OR OMISSIONS OF THE RELEASED PARTIES.
I have read and understand this agreement and I am aware that by signing to the right I am waiving certain legal rights, including the right to sue.*

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Parent / Guardian Signature

Liability Release

I, the parent/guardian of the registrant, agree that the registrant and I will abide by the rules of Louisiana Youth Seminar (“LYS”), LYS’s affiliates and sponsors, and Louisiana State University. Recognizing the possibility of injury and/or illness associated with the program (for example, walking to events, participating in skits, participating in long and late hours of activities, unsupervised downtime) and in consideration for LYS accepting the registrant for its program and activities, I hereby release, discharge, and agree to indemnify LYS and its Board of Directors members, Executive Committee, staff, volunteers, affiliates, vendors, organizations, sponsors and the LSU Board of Agricultural and Mechanical College, its directors, officers, employees, agents and volunteers from any and all claims by or on behalf of the registrant and/or myself as a result of or in any way related to the registrant’s participation in LYS, its program and activities, and/or transportation to or from same, which participation and/or transportation I hereby authorize. I hereby grant permission to an attending physician to render any medical and/or surgical treatment deemed necessary to relieve pain and/or preserve the life and/or health of my son/daughter. I understand that reasonable efforts will be made to avoid accidents and prevent illness, but I agree that LYS will not be responsible or liable for any illness or injury. I certify that the above history is true and complete to the best of my knowledge.
I have read and understand this agreement and I am aware that by signing to the right I am waiving certain legal rights, including the right to sue.*

Clear
Parent / Guardian Signature
Submitted Date*

MonthDayYear
Date
Parent/Guardian name signing above*

First NameLast Name

Payment

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Registration Options*

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Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Re-Enter Coupon Code*
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TOTAL PAID TODAY:
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Reply to Email
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Student Information

Recruiter Information

Media Release

LYS Delegate Code of Conduct

In Case of Emergency Contact Person

Student Medical Information

Over-the-counter Medical Release Form

Insurance Information

Covid-19 Waiver and Assumption of Risk

Liability Release

Payment