• Path to Leadership Conference Registration

    Please register for the Path to Leadership Conference by completing the form below. You must indicate what organization is responsible for payment so be sure to have that information available. If you have questions about the conference you can visit our website at: https://sites.google.com/view/njelkspeerleadership

  • Conference Registration Information:

    • Students must be in 6th to 8th grade only.
    • Be certain that all “Responsible for Payment” sections are completed. If using a purchase order, please indicate PO number.
    • All payments should be received prior to the conference
      Make all checks payable to: NJ State Elks Association
    • The $50 registration fee includes: light morning snack upon arrival, lunch, and conference materials.
    • Transportation to and from the conference is not included.
    • No refunds on cancellations received after 1/10/27. All cancellations received after this date will still require full payment.
  • The attendee is a(n)*
  • Sex*
  • Format: (000) 000-0000.
  • Ethnicity*
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Student Information

  • Have you previously attended the NJ State Elks Path to Leadership Conference?*
  • Are you a member of an Antler Lodge?*
  • What Organization are you representing?*
  • Grade*
  • Is there Parent/Guardian attending with you?*
  • Is there an Advisor Attending with you?*
  • Format: (000) 000-0000.

  • Elk Advisor Information

  • Have you attended this conference before as an advisor?*

  • Advisor Information

  • Have you attended this conference before as an advisor?*
  • What Organization are you representing?*

  • Health History

    Please answer the following health related questions. 

  • Is the participant allergic to any food or medication?*
  • Does the participant use an Epi-Pen? (If yes, you MUST bring it with you!)*
  • Does the participant have asthma?*
  • Does the participant use an inhaler? (If yes, you MUST bring it with you!)*
  • The following medications may be stocked in the Medical Room and are used on an as needed basis to manage illness and injury. Please place a check mark next to any medications that the participant should NOT take.*
  • Please check that appropriate box(es) regarding food restrictions.*
  • Medication Information - Please list all medications (including over the counter or nonprescription drugs) taken routinely. If no medication is taken, you may skip this section.
    Rows
  • Medical History - please answer the following: Has/does the participant...*
    Rows
  • Is the participant a diabetic?*
  • Does the participant take insulin?*
  • Is the participant hypoglycemic?*
  • Does the participant take oral glycemics?*
  • Is the participant currently under medical care?*
  • Is there anything we should know about the participant's mental health (include any specific diagnoses, difficulties, and/or major life events)?*
  • Is there anything else you'd like to tell us that we've forgotten to ask?*
  • Does the participant have a physician or clinic?*
  • Format: (000) 000-0000.

  • 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.*
  • Format: (000) 000-0000.
  • Policy Holder Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
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  • 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.

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Payment Information

    All invoices will be emailed to the person responsible for payment after January 10th. Please mail your payments once you have received the invoice.

    Payment must be mailed to:

    NJ State Elks Association
    Path to Leadership Conference
    PO Box 314
    Brielle, NJ 08730

  • Entity Responsible for Payment*
  • Format: (000) 000-0000.
  • Do you have a Purchase Order # or 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.

  • Release and Consent

    For students, this portion must be completed by your parent/guardian.  If you are an advisor, you are consenting to and acknowledging the following on behalf of yourself. (Both the students and advisors are hereinafter referred to as Participant)

    Consent for Attendance and Participation

    I hereby give permission for the Participant to attend the NJ State Elks Association Path to Leadership Conference in Long Branch, NJ and to participate in all, sessions, workshops, social and physical activities involved in the conference. Participant agrees to abide by all Conference Rules and comply with, observe and obey any instructions, or other requirements provided at the Conference by the Conference staff or hotel. Failure to follow such Rules or requirements could result in being requested to leave the conference immediately in which case parents will be called to pick up their child.

    Image Release Consent for Photographs

    I hereby give permission for photographs and audio & video recordings to be taken of the Participant and for their audio, image and likeness to be used in promoting and publicizing of the Conference.

    Medical Consents

    I hereby authorize appropriately trained personnel (EMT), or other trained personnel designated by the Elks, to administer first-aid and medical treatment to the Participant, if necessary. I further give my permission for the Participant to receive aspirin, Tylenol, or other over-the-counter medicine as specified in the application.

    In the event 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 in this application to give such consent. 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. If it is the opinion of the Conference Staff that Participant should go home due to illness, the parents, guardians or emergency contacts agree to immediately pick their child up when called, regardless of time.

    Release of Liability & Hold Harmless Agreement

    In consideration of the participation of the Participant in Conference, I hereby release and hold harmless the N.J. State Elks Association, their officers, agents, servants, employees, volunteers and any associated medical personnel, from and against any and all claims, liability or damages for injury or death to person or damage to property which may occur during or arise out of the Participant’s attendance and participation at the Elks Conference.

  • Initials*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Should be Empty: