2026 Nebraska Leadership Seminar Delegate Registration

2026 Nebraska Leadership Seminar Event Details: 
This event is open to current high school sophomores and juniors!

Dates: Thursday, June 11th through Sunday, June 14th, 2026
Location: Southeast Community College, Milford Campus 
600 S State St, Milford, NE 68405
Time: Check-in and check-out times will be shared in early Spring
Cost: Early Bird rate of $300 if registered by March 1st, 2026
Cost increases to $325 after March 1st
Registration closes May 1st, 2026

If you have questions about the form or any information on it, please contact registration@nebraskaleadership.org

Name*

First NameMiddle InitialLast Name

Gender*

MaleFemaleGender Non-BinaryOther

Preferred Pronouns*

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

High School*

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

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*

Area CodePhone Number

Work Phone Number*

Area CodePhone Number

Home Phone Number*

Area CodePhone Number

Nebraska Leadership Seminar, Inc. pays for HIPAA complance with JotForm, Inc. Your Health Information is protected and will not be shared with anyone. Nebraska Leadership Seminar, Inc. has a filed a Business Associate Agreement with JotForm, Inc. which protects your Protected Health Information. Please contact the Nebraska Leadership Seminar Recruitment Team at registration@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*

Area CodePhone Number

Allergies

Disabilities

Dietary Considerations/Restrictions

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 at their own discretion, however, we will contact you if Tylenol/Ibuprofen are needed and weren't brought with).

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

Activities: 2026 Nebraska Leadership Seminar

Dates: June 11th - 14th , 2026

Location: Southeast Community College - Milford, Nebraska

IN CONSIDERATION of the right to attend and participate in the Activities described above, the participant (and, if the Participant is a minor, their 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 they are 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, their 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

Seminar Rules

So that the seminar 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/legal guardian will be notified.

The seminar runs from Thursday afternoon to Sunday afternoon. YOU MUST make a commitment to STAY FOR THE ENTIRE EVENT. If you have a scheduling program, we strongly suggest offering the weekend to your school’s alternate.
You are expected to be on time for all seminar functions. You must attend all seminars and meals.
For security reasons, nametags must be worn at all seminar functions.
No outside guests are allowed in or around the seminar facility except for the closing ceremonies on Sunday.
Stay within your assigned group during seminar 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 seminar events.
Room visitation by members of the opposite sex is not permitted.
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 his or her counselor.
In case of emergency, contact your counselor or another staff member.
Lock your room doors at all times, whether you are in it or not.
Cell phones should be kept in the dorm room during the day, and may only be used at night after all activities have concluded. Any Delegate found using a cell phone during scheduled activities will have the cell phone confiscated, to be returned at the end of the day.
Any damage caused by a Delegate will be responsibility of that Delegate.
Delegates are not allowed to make room changes. You must be in your assigned room at the announced curfew and must remain in such until the start of activities the next morning.
You must observe the morning wake-up call and be on time to the first activity of the day.
Respect the rights of other Delegates and enter only those rooms and floors in which seminar-related activities are being held. Keep noise to a minimum.
If any Delegate drives themselves to seminar, they agree that they will not attempt to leave campus for the duration of the seminar. The Emergency Contact will be notified immediately if this is of concern.

Seminar Dress Code

Special dress for the seminar weekend:

Friday Night Dance – Neon color theme
Sunday Closing Banquet – Dress clothes (Business Casual)
Comfortable shoes -- We are on a college campus, so we will walk to all activities
The dress code for the rest of seminar is casual wear.

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

Super short shorts
Hats without a specific seminar purpose (outside activities, volunteer project, etc.)
Mini-skirts
Tops with bare shoulders, halter tops, tops showing the midriff, or revealing tops
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 Seminar 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/legal 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 Nebraska Leadership Seminar, Inc. cannot be responsible for any emergencies that result from inaccurately describing the participant’s medical history. Nebraska Leadership Seminar, Inc. pledges to take every precaution for the participant’s safety, and to keep the information secure.

Delegate: I agree to the Seminar 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 Seminar 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 student’s selection as a Delegate to this year’s Nebraska Leadership Seminar! 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/legal guardians aware of:

Check-In/Registration: Registration check-in time on Thursday, June 11th, 2026 will be shared via email in early Spring. Southeast Community College-Milford Campus is located at 600 S State St., Milford, NE, 68405. Check-in will be in Dunlap Center. There will be signs posted and staff available to direct you when you arrive at the dorms. You will receive your student's dorm assignment and be able to move belongings to Prairie or Meadow Halls.

Check-out: Seminar check-out time on Sunday, June 14th, 2026 will be shared via email in early Spring. Check-out will conclude following the Closing Banquet Ceremonies and will take place at the Welsh Center. All students will have their belongings at the gym and can leave after the banquet.

Parent/Legal Guardian Activities: Sunday, June 14th, 2026

Parents/Legal Guardians are encouraged to to attend the Nebraska Leadership Seminar Closing Banquet Ceremonies, and details will be shared via email in early Spring.

The cost of the Closing Banquet lunch is $25 per person (excluding the Delegate) and the deadline for reservation is May 1st, 2026. The reservation will be made below, and payment will be filled out on the payment form emailed to you after this form is received.

We do hope you will make every effort to attend the banquet, as this is a special accolade that you and your student should celebrate together. Thank you for giving us the opportunity to work with your talented student.

If you have any additional questions, please feel free email the Nebraska Leadership Seminar Recruitment Team at registration@nebraskaleadership.org or call/text the Board President, Ashley Orcutt, at (402) 580-3092. Ashley Orcutt will be your contact person throughout the 2026 Seminar, so please save the contact information below.

Ashley Orcutt

(402) 580-3092

ashley.orcutt@nebraskaleadership.org

Board President, Nebraska Leadership Seminar

I/We will attend the Closing Session/Banquet*

YesNo

I understand that the cost of the banquet is $25 per person (you do not have to pay for your delegate). I understand that I will need to submit the payment form that will be automatically emailed out after this form is submitted and pay via PayPal or check.*

Yes

Delegate Signature*

Parent/Guardian Signature*

Please verify that you are human*

2026 Nebraska Leadership Seminar Delegate Registration

Basic Information

Seminar Items

Emergency Contact

Medical History

Consent and Acknowledgement

Seminar Rules and Dress Code

Parent/Guardian Information

Signatures