NJ Elks Peer Leadership Conference

Insurance Information

I agree to pay any medical bills, either directly or through medical insurance payments, which may result from any treatment deemed necessary by medical personnel.
The participant is covered by medical insurance.*

YesNo
Insurance Company Name*
Insurance Company Phone Number*
Please enter a valid phone number.
Policy Holder Name*

First NameLast Name
Policy Holder Date of Birth*

MonthDayYear
Date
Policy Number*
Group Number*
Insurance Information - Please upload the front/back of the card.

Cancelof

Emergency Contact

In the event of an emergency, please provide two individuals that the Elks Staff may contact to provide medical authorization or for any other emergency matters.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relationship to the Participant *
(Example: Mother, Father, Aunt, Grandparent, etc.)
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relationship to the Participant *
(Example: Mother, Father, Aunt, Grandparent, etc.)

Payment Information

All invoices will be emailed to the person responsible for payment after December 15th. Please mail your payments once you have received the invoice. Be sure to include the invoice number on the check.

Payment must be mailed to:

NJ State Elks Association
Peer Leadership Conference
PO Box 314
Brielle, NJ 08730
Entity Responsible for Payment*

Elks LodgeSchoolMunicipal AllianceSelfOther
Please select your Elks Lodge:*
School:*
Municipal Alliance:*
Contact Person for Payment*

First NameLast Name
Contact Person Phone Number
Please enter a valid phone number.
Contact Person Email Address*
example@example.com
Do you have a Purchase Order # or Check #?*

Purchase Order #Check #No
Purchase Order #*
Check #*

Consent Form

For students, this portion must be completed by the parent/guardian of the participant. If you are an advisor you must complete this section for yourself.
I am the parent/guardian of: *

Participant First NameParticipant Last Name
Consent for Attendance

I hereby give permission for the Participant to attend the NJ State Elks Association Peer Leadership Conference in Long Branch, NJ. The above named individual shall be allowed to participate in all above mentioned informational and physical activities and workshops.
Initials*
Medical Consent

I hereby authorize appropriately trained personnel (EMT), or other trained personnel designated by the Elks, to administer first-aid treatment to the Participant, if necessary. In the event that the Participant suffers a serious injury or illness, I understand that the Elks will notify me as soon as possible to obtain my approval for treatment. If I am unavailable, I designate the emergency contacts provided on this form to give such consent.
Initials*
Emergency Contact

In the event that efforts to contact me or my designees are unsuccessful or are not possible during emergency circumstances, I hereby authorize the attending physician to administer any treatment including surgery which he or she deems necessary. I understand that I will, in any event, be contacted as soon as possible. I further give my permission for the Participant to receive aspirin, Tylenol, or other over-the-counter medicine under the supervision of the EMT on-site.
Initials*
Consent for Photographs

I hereby give permission for photographs to be taken of the participant, and for photographs in which participant is included to be used for purposes of publicity of the Elks Conference.
Initials*
Release of Liability

For an in consideration of the participation of the Participant in Elks program(s), I hereby release and hold harmless NJ State Elks Association, their officers, employees, volunteers or agents, and any medical personnel they select, from any and all liability or damages including accidental injury or illness which may occur during the Participant’s attendance at the Elks Conference.
Initials*
COVID-19 WAIVER/RELEASE

Due to the current Pandemic (COVID-19) attendees, parents, guardians and members of the attendees family understand that there are inherent risks associated with attending the New Jersey State Elks Association Peer Leadership Conference or Path to Leadership Conference and agree to assume all risks with regard to the
pandemic. The parent or guardian hereby agrees to voluntarily waive, release, defend, indemnify and hold harmless the New Jersey State Elks Association it’s local Lodges, members, volunteers, speakers, sponsors, agents, servants and employees of them against any damages, claims, lawsuits, liabilities, attorney fees or other losses which they may sustain, be subjected to, or caused to incur should the attendee be exposed to or contract COVID-19 or any other illness or injuries including death or otherwise. Attendee, parent or guardian agrees to observe and obey any instructions, warnings or other requirements provided at the Conference including wearing a mask properly, practice social distancing, participate in contact tracing, if necessary and any other guidelines that may be communicated at the conference or in advance of the conference. Failure to follow such guidelines could result in being requested to leave the conference immediately.
Initials*
Name of Parent/Guardian:*

First NameLast Name
Address of Parent/Guardian:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Day Phone Number*
Please enter a valid phone number.
Parent/Guardian Cell Phone Number*
Please enter a valid phone number.
Parent/Guardian Email*
example@example.com
Parent/Guardian Employer
Work Phone Number
Please enter a valid phone number.
Parent/Guardian Signature*

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Name:*

First NameLast Name
Email*
example@example.com
Signature:*

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	Name	Date Started	Reason	When is it given	Amount or dose given	How is it given (i.e. orally)
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	Yes/No	If yes, please explain
Ever been hospitalized?
Ever had surgery?
Have recurrent/chronic illnesses?
Had a recent infectious disease?
Had a recent injury?
Had asthma/wheezing/shortness of breath?
Had headaches or migraines?
Have seizures?
Wear glasses, contacts, corrective eyewear?
Had fainting or dizziness?
Passed out/had chest pain during exercise?
Had mononucleosis ("mono" in the past 12 months?
If menstruates, have problems with periods/menstruation?
Have problems with falling asleep/sleepwalking?
Ever had an eating disorder?
Have any skin problems?
Have a peanut allergy?
Have depression or anxiety?
Ever been treated for emotional or behavioral difficulties?

Peer Leadership Conference Registration