ASB 2019 - Youth Leader's Retreat, 03/22/2019, 9am-5pm @ Plantation Heritage Park - Fountain Room
Student & Guardian Information
Student First Name
Student Last Name
What School Do You Attend?
What Youth Group(s)/Club(s)/Organization(s) Are You A Member Of? Press (+) to list up to 5:
Do You Hold An Officer/Executive Board Position? If so, select which position:
Home Street Address
Address Line 2
Student Phone Number
Student Email Address
Legal Guardian First Name
Legal Guardian Last Name
Legal Guardian Phone Number
Legal Guardian Email Address
Parent's MUST sign electronically below.
I, Legal Guardian of the above named youth, give permission for my child to attend and participate in the Alternative Spring Break Youth Leader's Retreat on Friday, March 22nd 2019 if my child is selected to attend.
In addition, I will ensure that my child will arrive to the event location by 9am and will be picked up no later than 5pm. I understand that no staff supervision will be provided after 5:15pm.
Photo / Media Release
I do hereby give United Way of Broward County their assigns, licensees, and legal representatives the irrevocable right to use my child’s name / or any fictional name, photograph image and/or statement(s) in all forms and media and in all manners, including composite or distorted representations, for advertising, trade or any other lawful purposes, including on printed advertising and promotional material and on websites and other electronic media and I waive any right to inspect or approve the finished version(s), including written copy that may be created in connection therewith. This consent is expressly intended to release United Way of Broward County from liability. I am of legal age and have read this release and am fully familiar with its contents.
Check your inbox regularly for more information and updates. Emilia Vilaire-Monchery, Prevention Specialist, EVilaire@unitedwaybroward.org