2024 IL HPP Student Leadership Workshop: 10/9/24 @BHS

We're so glad you're interested in attending the 2024 IL HPP Student Leader Workshop!

This workshop is a collective of students from local schools in your area.

By completing this paperwork alongside a parent/guardian, you are consenting to participating in the 2024 IL HPP Student Leader Workshop.
I am completing this participation form as a:*

Student participantStaff participant

Participant Information

Please provide us with as much information as possible to provide the best support during the event.
Name*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Gender:*
Name of School:*
Grade Level:*
Position/Title:
Participant Email Address:*
example@example.com
Participant Phone Number

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Emergency Contact Information

Please provide us with at least one parent/guardian information in case of emergencies and for their permission for your participation.
Parent/Guardian Name:*

First NameLast Name
Relation to Participant:*
Parent/Guardian Email Address:*
example@example.com
Parent/Guardian Phone Number:*

Area CodePhone Number
Second Parent/Guardian Name (Optional):

First NameLast Name
Relation to Participant (Optional):
Second Parent/Guardian Email Address (Optional):
example@example.com
Second Parent/Guardian Phone Number (Optional):

Area CodePhone Number
Emergency Notification

Please verify if the person(s) listed above can be contacted in the event of an emergency during the event.
I authorize OMNI/ IL HPP staff or volunteers to contact the person(s) identified in the event of an emergency. I understand that such notification may necessitate that certain information regarding my condition or treatment be released, but only to the extent that said information is necessary to address the emergency. This consent will be in effect for the duration of my involvement with the IL Human Performance Project through OMNI Youth Services, but may be revoked or revised at my discretion through a written request delivered to the Program Director.I DO NOT authorize OMNI/ IL HPP staff or volunteers to contact the person(s) identified in the event of an emergency. I understand that such notification may necessitate that certain information regarding my condition or treatment be released, but only to the extent that said information is necessary to address the emergency. This consent will be in effect for the duration of my involvement with the IL Human Performance Project through OMNI Youth Services, but may be revoked or revised at my discretion through a written request delivered to the Program Director.
Participant Signature & Date*

Clear
Participant's Guardian Signature & Date*

Clear
Consent for Services and Release of Photography/Video
I/We parent/guardian name(s)*, hereby grant permission on behalf of student participant name* to:
I parent/guardian name(s)*, hereby grant permission to:
1. OMNI Youth services/IL Human Performance Project to provide my child prevention programming and services. I understand that such permission may be revoked, in writing, at any time. As an OMNI Youth Services/IL Human Performance Project service recipient, I have the right to refuse program services.

2. OMNI Youth Services/IL Human Performance Project to publish or release photographs or videotape of participant named above. Providing consent to OMNI Youth Services and the IL Human Performance Project for releasing photographs and/or videotape is voluntary and will not impact the services I am currently involved in, or may be involved with in the future. I/We understand that the photographs/videotape may be used for one or more of the following purposes: brochures/ publications, advertisements, flyers, grant reports, OMNI Youth Services and/or IL Human Performance Project web page and/or social networking sites, office reception areas, and promotional videotapes. If you are opposed to one or more of these uses for photo or videotape, check the box indicating so below and sign. This consent is subject to written revocations at any time except to the extent that release or publication has already occured. This consent must be revoked in writing to be considered invalid. I understand that these are photographs or videos that may be taken while I engage in OMNI Youth Services and/or IL Human Performance Project facilitated events. It is understood that a refusal to authorize the release of photographs/videotape will prevent disclosure to the person/organization identified above.
Check only if you do NOT consent to the above photography and video release listed in item 2, but still do consent to services as listed in item 1.
Participant Signature & Date*

Clear
Participant's Guardian Signature & Date*

Clear
Event Questionnaire

Please provide us with information to best support your needs and interests for this upcoming virtual event.
Please indicate if you have any food allergies or medical concerns/restrictions below
Registration Payment Page
This event has a $15 registration fee, click on the "Registration Payment Page" above and indicate in the drop down menu below that you have either individually paid or confirmed your school advisor/chaperone/staff/teacher will be covering your fee.
Should be Empty:

Participant Information

Parent/Guardian Emergency Contact Information

Emergency Notification

Consent for Services and Release of Photography/Video

Event Questionnaire