NCBW Chicago Metro - Advocacy Leadership Academy Conference

Advocacy Leadership Academy Conference

Black Girls Leading the Charge for Change through Advocacy, Activism and Policy
The mission of the the Advocacy Leadership Academy Conference is to create future leaders by preparing black girls to lead and implement positive changes within their communities through activism, advocacy and public policy.

The National Coalition of 100 Black Women, Chicago Metropolitan Chapter will host a one day conference at Kennedy King College on Saturday, October 4, 2025 from 10A-2P with up to 100 black female students grades 9th-12th from the Chicagoland area.

NCBW, Chicago Metropolitian Chapter aims to provide them with tools for becoming future leaders within their communities and schools. They will be introduced to critical women who are leaders in local and state politics. They will learn strategies from women who are currently advocating for black women and girls through community activism and within their career fields.

This form must be signed by a Parent or Guardian who is 18 years of age or older.
Are you registering an individual or group?*

STUDENT INFORMATION
Student Name*

First NameLast Name
Grade *
Name of School*
ex: Chicago High School
Shirt Size*
Please let us know if you have any dietary restrictions or preferences. You may select all that apply:*

NoneVegetarianVeganGluten-FreeDairy-Free / Lactose IntolerantNut AllergyShellfish AllergyHalaOther

STUDENT INFORMATION
Did you attend Advocacy Leadership Conference in 2024 or Legislative Day 2025?
What are your two top areas of interest? (Please choose up to 2)

Impacting change through policy(supporting specific bills, connecting with local lawmakers)Locating available youth resources (summer jobs, cultural workshops, programs in the arts, funding for small businesses, etc.)Organizing to combat community issues (missing girls, neighborhood crime, gun violence, etc.)Growing your leadership skills (student government, civic leadership, school leadership, etc.)Mental and physical well-being (meditation, healthy lifestyle, nutrition, hygiene, etc.)
List one thing that you would like to learn/gain from attending this event?

Group Registration

This form is intended for groups with more than 5 participants. To include additional participants, please select 'Add Row'.
Please indicate the name of the school or group:
Configurable list*

PARENT/GUARDIAN INFORMATION
If applicable, please identify the school or community group you represent
Parent/Guardian Name*

First NameLast Name
Parent//Guardian Phone Number*
Parent/Guardian E-mail*
example@example.com
Will you be staying at the event?

WAIVER AND RELEASE OF LIABILITY
IN CONSIDERATION OF the risk of injury that exists while participating in ADVOCACY LEADERSHIP ACADEMY (hereinafter the "Activity"); and

IN CONSIDERATION OF my desire to participate in said Activity and being given the right to participate in same;

I HEREBY, for myself, my heirs, executors, administrators, assigns, or personal representatives (hereinafter collectively, "Releasor," "I" or "me", which terms shall also include Releasor's parents or guardian if Releasor is under 18 years of age), knowingly and voluntarily enter into this WAIVER AND RELEASE OF LIABILITY and hereby waive any and all rights, claims or causes of action of any kind arising out of my participation in the Activity; and

I HEREBY release and forever discharge NATIONAL COALITION OF 100 BLACK WOMEN, CHICAGO METROPOLITAN CHAPTER, their affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns (collectively "Releasees"), from any physical or psychological injury and or loss of property that I may suffer as a direct result of my participation in the aforementioned Activity.
I AM VOLUNTARILY PARTICIPATING IN THE AFOREMENTIONED ACTIVITY AND I AM PARTICIPATING IN THE ACTIVITY ENTIRELY AT MY OWN RISK. I AM AWARE OF THE RISKS ASSOCIATED WITH PARTICIPATING IN THIS ACTIVITY, WHICH MAY INCLUDE, BUT ARE NOT LIMITED TO: PHYSICAL OR PSYCHOLOGICAL INJURY, PAIN, SUFFERING, ILLNESS. I UNDERSTAND THAT THESE INJURIES OR OUTCOMES MAY ARISE FROM MY OWN OR OTHERS' NEGLIGENCE, CONDITIONS RELATED TO TRAVEL TO AND FROM THE ACTIVITY, OR FROM CONDITIONS AT THE ACTIVITY LOCATION(S). NONETHELESS, I ASSUME ALL RELATED RISKS, BOTH KNOWN AND UNKNOWN TO ME, OF MY PARTICIPATION IN THIS ACTIVITY.

I FURTHER AGREE to indemnify, defend and hold harmless the Releasees against any and all claims, suits or actions of any kind whatsoever for liability, damages, compensation or otherwise brought by me or anyone on my behalf, including attorney's fees and any related costs.

I FURTHER ACKNOWLEDGE that Releasees are not responsible for errors, omissions, acts or failures to act of any party or entity conducting a specific event or activity on behalf of Releasees. In the event that I should require medical care or treatment, I authorize National Coalition of 100 Black Women, Chicago Metropolitan Chapter to provide all emergency medical care deemed necessary, including but not limited to, first aid, CPR, the use of AEDs, emergency medical transport, and sharing of medical information with medical personnel. I further agree to assume all costs involved and agree to be financially responsible for any costs incurred as a result of such treatment. I am aware and understand that I should carry my own health insurance.

I HEREBY ACKNOWLEDGE THAT I HAVE CAREFULLY READ THIS "WAIVER AND RELEASE" AND FULLY UNDERSTAND THAT IT IS A RELEASE OF LIABILITY. I EXPRESSLY AGREE TO RELEASE AND DISCHARGE National Coalition of 100 Black Women, Chicago Metropolitan Chapter AND ALL OF ITS AFFILIATES, MANAGERS, MEMBERS, AGENTS, ATTORNEYS, STAFF, VOLUNTEERS, HEIRS, REPRESENTATIVES, PREDECESSORS, SUCCESSORS AND ASSIGNS, FROM ANY AND ALL CLAIMS OR CAUSES OF ACTION AND I AGREE TO VOLUNTARILY GIVE UP OR WAIVE ANY RIGHT THAT I OTHERWISE HAVE TO BRING A LEGAL ACTION AGAINST National Coalition of 100 Black Women, Chicago Metropolitan Chapter FOR PERSONAL INJURY OR PROPERTY DAMAGE.

To the extent that statute or case law does not prohibit releases for ordinary negligence, this release is also for such negligence on the part of National Coalition of 100 Black Women, Chicago Metropolitan Chapter, its agents, and employees.
I agree that this Release shall be governed for all purposes by law, without regard to any conflict of law principles. This Release supersedes any and all previous oral or written promises or other agreements.

In the event that any damage to equipment or facilities occurs as a result of my or my family's or my agent's willful actions, neglect or recklessness, I acknowledge and agree to be held liable for any and all costs associated with any such actions of neglect or recklessness.

THIS WAIVER AND RELEASE OF LIABILITY SHALL REMAIN IN EFFECT FOR THE DURATION OF MY PARTICIPATION IN THE ACTIVITY, DURING THIS INITIAL AND ALL SUBSEQUENT EVENTS OF PARTICIPATION.

THIS AGREEMENT was entered into at arm's-length, without duress or coercion, and is to be interpreted as an agreement between two parties of equal bargaining strength. Both Participant,blanksand National Coalition of 100 Black Women, Chicago Metropolitan Chapter agree that this agreement is clear and unambiguous as to its terms, and that no other evidence shall be used or admitted to alter or explain the terms of this agreement, but that it will be interpreted based on the language in accordance with the purposes for which it is entered into.


In the event that any provision contained within this Release of Liability shall be deemed to be severable or invalid, or if any term, condition, phrase or portion of this agreement shall be determined to be unlawful or otherwise unenforceable, the remainder of this agreement shall remain in full force and effect. If a court should find that any provision of this agreement to be invalid or unenforceable, but that by limiting said provision it would become valid and enforceable, then said provision shall be deemed to be written, construed and enforced as so limited.

In the event of an emergency, please contact the following person(s) in the order presented:

Emergency Contact First Name*   Emergency Contact Last Name*

Relationship to Student*

Area Code*   Phone Number*

I, THE UNDERSIGNED PARTICIPANT, AFFIRM THAT I AM OF THE AGE OF 18 YEARS OR OLDER, AND THAT I AM FREELY SIGNING THIS AGREEMENT. I CERTIFY THAT I HAVE READ THIS AGREEMENT, THAT I FULLY UNDERSTAND ITS CONTENT AND THAT THIS RELEASE CANNOT BE MODIFIED ORALLY. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT AND THAT I AM SIGNING IT OF MY OWN FREE WILL.

Student First Name*  Student Last Name*

  Student Street Address   Address Line 2

  City   State   Zip

I, THE UNDERSIGNED GUARDIAN/PARENT FOR THE PARTICIPANT, AFFIRM THAT I AM THE LEGAL GUARDIAN OR THE PARENT OF THE PARTICIPANT AND I HAVE THE AUTHORITY TO SIGN ON BEHALF OF THE PARTICIPANT. I CERTIFY I HAVE READ THIS AGREEMENT, THAT I FULLY UNDERSTAND ITS CONTENT AND THAT THIS RELEASE CANNOT BE MODIFIED ORALLY. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT AND THAT I AM SIGNING IT OF MY OWN FREE WILL.

Signature of Student

Signature of Parent/ Guardian if under 18 years of age:

PARENT/GUARDIAN WAIVER FOR MINORS
In the event that the participant is under the age of consent (18 years of age), then this release must be signed by a parent or guardian, as follows:

I HEREBY CERTIFY that I am the parent or guardian of blanks named above, and do hereby give my consent without reservation to the foregoing on behalf of this individual.

Parent/Guardian First Name   Last Name

Relationship To Minor

Signature       Date

I, First Name Last Name (parent or legal guardian), for and in consideration of the participation of my child/youth First Name Last Name (name of youth) in the Advocacy Leadership Academy, offered by the Chicago Metropolitan Chapter of the National Coalition of 100 Black Women, Inc., and in which I freely and voluntarily permit my child to participate, do hereby agree and understand not to hold the Chicago Metropolitan Chapter of the National Coalition of 100 Black Women, Inc., their officers, administrators, employees, representatives and/or agents, and their heirs, successors, and assigns, liable in any way, what so ever, for any injury, or damage, or loss of property sustained by my child or persons other than my child arising out of, or in connection with, or due to negligence, fault, or otherwise during any part of my child’s participation in the aforementioned program.

For the same consideration and without conflict in the foregoing, voluntarily and knowingly, I hereby release and discharge the Chicago Metropolitan Chapter of the National Coalition of 100 Black Women, Inc., officers, administrators, employees, representatives and/or agents, and their heirs, successors, and assigns, both in their official and individual capacities jointly and severally, from any actions, causes of action, claims, demands, damages, costs, and expenses on account or in any way growing out of any and all loss of personal property, or injury, as the result of any accident, delay, or irregularity which may be caused either in whole or in part by any defect in any vehicle, airplane, vessel, or negligent operation thereof and through any act, error, or omission, or default of any company or person, or by reason of the conditions or use of any real or personal property while I am in route to, or from or participating in the program or occasioned by it.

I further promise to bind myself, and all my heirs, administrators, and executors, to indemnify and forever hold harmless the Chicago Metropolitan Chapter of the National Coalition of 100 Black Women, Inc., their officers, administrators, employees, representatives and/or agents against loss, damage, or expense from any and all claims, demands, actions, or causes of action that may occur while in route to, or from, or participating in the program or any activity relating or occasioned by it.

Additionally, I will provide my child’s report card (as requested) to allow facilitators to monitor academic progress. I have read this release, understand the contents, and execute it voluntarily and with full knowledge of its impact.
IMAGE RELEASE
Requesting Entity: National Coalition of 100 Black Women, Chicago Metropolitan Chapter

As the Subject identified above by Full Name, I hereby consent to and authorize the Requesting Entity (identified above) and its successors, assigns, licensees and agents (collectively, “the Entity”) to photograph, video or otherwise capture my visual and/or aural likeness, and to reprint, publish, edit and distribute any and all captured photographs/videos/recordings (collectively, “likenesses”) in connection with the Entity’s advertising, promotion and publications in print, video, digital or other form of media known or hereafter developed, including but not limited to the Entity’s website, social-media platforms, and on signage or materials related to its events.

I understand that I hereby assign all rights for these likenesses to the Entity. I further acknowledge and agree that I will receive no monetary payment, royalties or other remuneration of any kind for the use of the likenesses. I hereby waive, release and forever discharge the Company from any and all claims, demands or liabilities arising out of or in connection with the use of the likenesses.
Subject’s affiliation: if applicable
If subject’s name should be referenced differently in captions, please indicate so here:
Please indicate below:*

Please check here to verify that the Subject is 18 years old.Please check here to verify that the information above is accurate.
Advocacy Leadership Academy Conference

Black Girls Leading the Charge for Change through Advocacy, Activism and Policy
Acknowledgment. I have read and agree to the terms outlined in the Consent, Waiver of Liability, and Image Release Form.*

Yes, I have read and agree to the terms.No, I do not agree to the terms
Signature*

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Advocacy Leadership Academy Conference

STUDENT INFORMATION

STUDENT INFORMATION

Group Registration

PARENT/GUARDIAN INFORMATION

WAIVER AND RELEASE OF LIABILITY

PARENT/GUARDIAN WAIVER FOR MINORS

IMAGE RELEASE

Advocacy Leadership Academy Conference