2024 NMBSA/BSU Academic State Conference Registration

2024 NMBSA/BSU Academic State Conference Registration
Name*

First NameLast Name
School Information*

School Grade/Year
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Email (Please use an email that you have access to when school is out)*
example@example.com
Parent(s) Information

For students under 18 years of age.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Information *

Primary PhoneNumber Other Phone Number
Do you need travel? (For Individuals outside of the Albuquerque Metro Area)*

YesNo
If so, please share the city in which you live.
Do you have any food restrictions?*

YesNo
If so, what are your restrictions?
Do you have any health /medical issues that need to be addressed?*

YesNo
If so, please explain?
Do you have any special accommodations that are needed?*

YesNo
If so, please explain?

Permission to Participate and Authorize for Medical Services
I, Parent Name ,parent or guardian of Child's Name hereby give my child permission to participate in the NMBSA/BSU State Academic Conference.
I hereby assume financial responsibility for any and all hospitalization and medical treatment provided. A copy of this form will be with the New Mexico Office of African American Affairs. Prescribed medication should be kept with sponsor/chaperone at all times.

Prescribed medication minor is taking: Name of Prescription
Allergies to food or medicine:   Name of Food or Medicine
I authorize the New Mexico Office of African American Affairs to obtain any medical care that may become necessary to Child's Name   in course of such activity. In the event medical care becomes necessary, all efforts will be made to notify parents or guardians.

I agree to not hold the Office of African American Affairs, my child's sponsor, chaperone, or anyone acting on the behalf of the aforementioned organizations, responsible for the action of my child during the program or for injury occurring to my child during the program.

I understand that all state, local and federal laws apply throughout the duration of the program. The parent or guardian will be called on to assume responsibility for and all damages that may result from any prohibited action the minor may take while attending the NMBSA/BSU State Academic Conference.
I give my child permission to attend any Office of African American Affairs sponsored events that may occur during the NMSA/BSU State Academic Conference.
Parent/ Guardian Signature

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Contact Information   Area Code   Phone Number
Relationship   Relationship to Child
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2024 NMBSA/BSU Academic State Conference Registration

Parent(s) Information

Permission to Participate and Authorize for Medical Services