Speakers Bureau 2019 Registration

Speakers Bureau Training 2019

August 27-29, 2019

You must be a member of Blind Beginnings to register for this workshop. If you are not already a member, please complete our Membership Form first.

Youth's First Name:*
Youth's Last Name:*
Gender
- Male
- Female
Youth's Email
Parent's Email
Parents' Names:
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Mobile Phone
Date of Birth
Medical Health Care #
Visual Impairment Diagnosis
Do you have any allergies or dietary restrictions? If yes, please explain:
Is there anything else we should know about you that might impact your participation in this training?
Emergency Contact
This information is essential to ensure that Blind Beginnings staff can respond appropriately to an emergency. *Note: Blind Beginnings does NOT have a nurse or doctor on site and staff may only dispense medications.
Contact Full Name
Relationship
Contact Home Phone
Contact Work Phone
Contact Mobile Phone
Contact City
Medical Treatment Release
I give permission for Blind Beginnings, its staff, employees, servants and agents to obtain for my child such medical aid and treatment as he/she may need for him/her to maintain health and well being while attending the program.
Enter Your Full Name
Waiver of Claim
In consideration for services and other good and valuable consideration provided to me by Blind Beginnings and participating community partners, I, on behalf of my child or child for whom I have guardianship, agree to indemnify and save harmless Blind Beginnings and community partners, its organizers, agents, officials, servants and representatives from all liability and, without limiting the generality of the foregoing, from all claims, loss, damage, injury, liability, costs and expenses of whatsoever kind or nature (including legal fees) howsoever the same may be caused resulting directly or indirectly from the above mentioned work and/or services provided to me by Blind Beginnings and community partners, by its organizers, agents, officials, servants and representatives, notwithstanding that the same may have been contributed to or occasioned by (their) negligence.
Enter Your Full Name
Video & Photo Release
I hereby consent for my minor daughter/son/wards, to be video taped, and/or photographed during the Youth Leadership Training Weekend (April 20 – April 22, 2018), with the understanding that the photos and videotape materials will be used for teaching and/or future program promotional needs. I consent to the use of her/his full names in connection with any such photo or videos.
Enter Your Full Name
Date
Date Format: MM slash DD slash YYYY
Untitled
Name
This field is for validation purposes and should be left unchanged.

Speakers Bureau Training 2019

Emergency Contact

Medical Treatment Release

Waiver of Claim

Video & Photo Release