2025 Nebraska Leadership Seminar Kickstart Delegate Registration

Activity: 2025 NLS Kickstart

Date: Saturday, 07/12

Location: Osceola High School

565 S Kimmel St, Osceola, NE 68651

Time:

Check-in: 8:30am-10:00am

Check-out: 5:00pm-6:00pm

Cost: $50

Registration closes 05/28

If you have questions about the form or any information on it, please contact Ashley Orcutt, NLS Board President, at ashley.orcutt@nebraskaleadership.org

Name*

First NameMiddle InitialLast Name

Gender*

MaleFemaleGender Non-BinaryOther

Preferred Pronouns

He/Him/HisShe/Her/HersThey/Them/TheirOther

High School*

Grade (2024-2025 school year)*

School Counselor Email*

Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Student Email - Preferably not a school email. You will receive the majority of information, so please check regularly*

example@example.com

Parent Email - Preferably not a school email.*

example@example.com

Please upload a recent, clear photo of the student's face (headshot style). This will assist staff with check-in, group coordination, and in the event of an emergency.

Preferred Name for Name Tag*

First NameLast Name

T-Shirt Size*

Name - This person must be 21 years or older*

First NameLast Name

Relationship*

Parent/GuardianGrandparent/GuardianFamily FriendOther

Phone

Only one phone number is required, but please provide all numbers possible.

When you enter one phone number, the other two become unrequired. Please provide all numbers possible.

Cell Phone Number*

Work Phone Number*

Home Phone Number*

Nebraska Leadership Seminar, Inc. pays for HIPAA compliance with JotForm, Inc. Your Health Information is protected and will not be shared with anyone. Nebraska Leadership Seminar, Inc. has filed a Business Associate Agreement with JotForm, Inc. which protects your Protected Health Information. Please contact Ashley Orcutt, NLS President, via email ashley.orcutt@nebraskaleadership.org if you have any concerns.

Delegate Date of Birth*

Date

Does the Delegate have a Primary Care Physician that they see?*

YesNo

Delegate Physician*

Physician Clinic/Hospital Name*

Physician Phone*

Disabilities

Allergies

Dietary Considerations/Restrictions

Special Needs (please list anything you need to make sure your experience is the best possible)

Health Insurance

Please select whether or not the Delegate is covered by Health Insurance. If the Delegate is NOT covered by Health Insurance, please select No below and move to the next section. If the Delegate IS covered by Health Insurance, please select Yes below and input the Plan Name and Member Number/ID.

The Plan name is the company that provides the Health Insurance.

The Plan/Member ID/Number varies per company. If you are not sure what number to put down, please put down all numbers on the card. Below are examples of Plan Numbers...

Blue Cross Blue Shield: XYZ123456789

Aetna: W1234 56789

United Healthcare/UMR/Medica: 123456789

Other: Put your plan number/member ID. If you are not sure which number it is, put down all numbers on the card.

Is the Delegate covered by Health Insurance?*

YesNo

Health Insurance Plan Name*

Example: Blue Cross Blue Shield, Aetna, United Healthcare, UMR, Medica, etc.

Health Insurance Plan/Member ID/Number - If you are unsure what number to put, please include ALL numbers on the card*

Please list the name of any medication you are taking, the dosage, and the condition that requires you to take the medication (students can take their own medications without our knowledge, however, we will contact you if Tylenol/Ibuprofen are needed and weren't brought with).

Please list anything else you would like us to be aware of so that we may accommodate as best as we can.

IN CONSIDERATION of the right to attend and participate in the Activities described above, the participant (and, if the Participant is a minor, his or her parent or legal guardian) hereby.
Agrees to abide by all rules and regulations established by the Nebraska Leadership Seminar, Inc. (“NLS”).
Authorizes NLS or any of its agents to provide, obtain, or authorize any reasonable incidental and/or emergency medical treatment for the Participant, in the event of the Participant’s illness, injury, or incapacity, and hereby accepts the responsibility to pay for such treatment.
Grants to NLS for any purpose connected with promoting the purposes and goals of NLS, but not for commercial exploitation, the right to use, reproduce, publish and distribute the Participant’s name, voice, and likeness, and any biographical information submitted by the Participant to NLS in any writings, photographs, films, and recordings of the Participant while he or she is participating in the activities.
Acknowledges that there is an element of risk involved in any activity involving travel outside of one’s own home or community; certifies that the Participant is physically, mentally, and emotionally capable of attending and participating in the activities; assumes all risk and financial responsibility for any loss or injury to the Participant or others that may occur as a result of the Participant’s negligence or misconduct; and indemnifies and holds NLS harmless from and against any and all costs, claims, demands, charges, liabilities, obligations, judgments, executions, costs of the suit and actual attorneys’ fees incurred or suffered by NLS as a result of, or arising out of, the Participant’s negligence or misconduct.
This Consent and Acknowledgment of risk shall not be amended, supplemented, or abrogated without the written consent of NLS.
The Participant (and, if the participant is a minor, his or her parent or legal guardian) has read this Consent and Acknowledgment of risk, and understands its contents.

Delegate: I agree to the Consent and Acknowledgement terms above and certify that my signature at the end of this form is my own. My signature, as well as selecting "Yes" below, shows that I have read the above statements and agree to the terms.*

Yes

Parent/Guardian: I agree to the Consent and Acknowledgement terms above and certify that my signature at the end of this form is my own. My signature, as well as selecting "Yes" below, shows that I have read the above statements, agree to the terms, and provide consent for my delegate.*

Yes

NLS Kickstart Rules

So that the Kickstart may be conducted as efficiently as possible, we ask that you observe the following rules. Any participant who does not abide by these rules and regulations will be dismissed and your parents will be notified.

The NLS Kickstart runs from 10:00am to 5:00pm on Saturday, 07/12. YOU MUST make a commitment to STAY FOR THE ENTIRE EVENT. If you have a scheduling program, we strongly suggest offering the opportunity to your school’s alternate.
For security reasons, nametags must be worn at all times.
No outside guests are allowed in or around the facility during the event beyond those commuting students to the event during the dropoff and pickup windows from 8:30am-10:00am and 5:00pm-6:00pm.
Stay within your assigned group during NLS Kickstart sessions. Gain permission from your counselor if you must leave a session and wait for an adult staff member to escort you. No delegate is to leave the facility except for scheduled Kickstart community service events.
No tobacco products (including electronic/vaping equipment), drinking of alcoholic beverages, and/or unauthorized drug use is permitted.
Any delegate who has a medical problem that requires special care, treatment, or medication is asked to inform their counselor.
In case of emergency, contact your counselor or another staff member.
Cell phones should be kept in your bag during the day. Any Delegate found using a cell phone during scheduled activities will have the cell phone confiscated by their group counselor, to be returned at the end of the day.
Any damage caused by a Delegate will be responsibility of that Delegate.
Respect the rights of other Delegates, any violations of this will prompt immediate contact to their parents and dismissal from the NLS Kickstart.
If any Delegate drives themselves to NLS Kickstart, their car keys may be held by their counselor until the end of the Kickstart event.

NLS Kickstart Dress Code

Please wear school-appropriate clothing. Dress comfortably for movement, group activities, and possible outdoor activities.

The following is a specific list of clothing and appearance items that are prohibited:

Super short shorts
Mini-skirts
Tops with bare shoulders, halter tops, tops showing the midriff, or revealing tops
Any sagging pants or clothing that exposes undergarments
If you wear a hat, plan to remove while inside
Any clothing with offensive language or messages or clothing that advocates or references sex, drugs, alcohol, or any other inappropriate subject

In addition to the specific items set forth in this Dress Code, it is understood by all delegates that the Event Planning Chairs, President of the Corporate Board, and/or Alumni Advisor have the specific power to decide what is and what is not appropriate to wear during the seminar.

Illegal Activity

In the event illegal activity is observed (for example: tobacco usage, vaping, alcohol consumption), parents/guardians and possibly the authorities will be notified immediately.

Certification

I certify that the information included on this is complete and true to the best of my knowledge. I understand that NLS cannot be responsible for any emergencies that result from inaccurately describing the participant’s medical history. NLS pledges to take every precaution for the participant’s safety, and to keep the information secure.

Delegate: I agree to the NLS Kickstart Rules and Dress Code above and certify that my signature at the end of this form is my own. My signature, as well as selecting "Yes" below, shows that I have read the above statements and agree to the Rules and Dress Code.*

Yes

Parent/Guardian: I agree to the NLS Kickstart Rules and Dress Code above and certify that my signature at the end of this form is my own. My signature, as well as selecting "Yes" below, shows that I have read the above statements, agree to the Rules and Dress Code, and provide consent for my delegate.*

Yes

Congratulations on your child’s selection as a Delegate to this year’s Nebraska Leadership Seminar Kickstart! This achievement is quite an honor and both you and your student should be proud.

There are a few things we want to make parents aware of:

Date: Saturday, 07/12

Location: Osceola High School, located at 565 S Kimmel St, Osceola, NE 68651.

Check-In/Registration: Registration check-in will be from 8:30am-10:00am on Saturday, 07/12. Please be sure your child eats breakfast before arriving for check-in.

Check-out: Check-out will be from 5:00pm-6:00pm on Saturday, 07/12. All students will be dismissed at 5:00pm to collect their belongings and check-out with our registration team once ready to depart.

Payment: Please fill out the payment form found on the confirmation page of this form to complete registration. This link will also be emailed to you. If a school or organization is sponsoring the delegate, please share the link with them.

https://form.jotform.com/NebraskaLeadership/kickstartpayment

If you have any additional questions, please feel free to call or text the NLS Board President, Ashley Orcutt. Ashley will be your contact person throughout the NLS Kickstart, so please save the contact information below.

Ashley Orcutt

(402) 580-3092

ashley.orcutt@nebraskaleadership.org

NLS Board President

Delegate Signature*

Parent/Guardian Signature*

Please verify that you are human*

2025 Nebraska Leadership Seminar Kickstart Delegate Registration

Basic Information

NLS Kickstart Items

Emergency Contact

Medical History

Consent and Acknowledgement

NLS Kickstart Rules and Dress Code

Parent/Guardian Information

Signatures