2025 IL HPP Student Leadership Workshop Registration

2025 ILHPP Student Leadership Workshop

We're so glad you're interested in attending the 2025 IL HPP Student Leadership 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 2025 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
Participant Email Address *
example@example.com
Name of school: *
Grade Level *
Participant Phone Number *
Please enter a valid phone 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
Relationship to student: *
Parent/Guardian Email:*
example@example.com
Parent/Guardian Phone Number*
Please enter a valid phone number.
Second Parent/Guardian Name (Optional)

First NameLast Name
Parent/Guardian #2 Email
example@example.com
Parent/Guardian #2 Phone Number
Please enter a valid phone 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.
Particiant Signature*

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Parent/Guardian Signature*

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Consent for Services and Release of Photography/Video
I/We parent/guardian name* herby grant permission on behalf of student particiant name* 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.
Particiant Signature*

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Parent/Guardian Signature*

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Event Questionnaire
Please indicate if you or your student have any food allergies or medical concerns/restrictions below:
Event Payment

REGISTRATION PAYMENT PAGE LINKED HERE
This event has a $20 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.

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
Participant Email Address *
example@example.com
Name of school: *
Position/Title*
Participant Phone Number *
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
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.
Particiant Signature*

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Consent for Services and Release of Photography/Video
I staff name* herby grant permission to:

1. OMNI Youth services/IL Human Performance Project to provide me with 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.
Particiant Signature*

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Event Payment

REGISTRATION PAYMENT PAGE LINKED HERE
This event has a $20 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.
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2025 ILHPP Student Leadership Workshop