Omega Psi Phi Fraternity, Inc

12TH DISTRICT

YOUTH LEADERSHIP CONFERENCE APPLICATION

May 21, 2016
(PLEASE PRINT NEATLY)

1. Participants name___________________ ___________________ _______

(First)
(Last)
(MI)
2. Parents/Legal Guardians name___________________________________________
3. Street Address____________________________________________________________
4. City/State/Zip_____________________________________________________________
5. Telephone Number: (
Student cell number (

)________________ Parent Cell(

)_________________

)______________

GPA: ________

Email:_____________________________________ @ on Instagram________________
6. Name of school you attend:________________________________________________
7. Current Classification: ____9th ___10th

___11th

___12th

8. After graduating from high school, do you plan to further your education?
___Yes ___No
9. What is your occupational goal(s)____________________________________
10. List activities you are involved in (student organizations, sports, community, etc.)
______________________________________________________________________________________
______________________________________________________________________________________

______________________________________________________________________________
______________________________________________________________________________
11. T-shirt Size

S ____ M ____ L ____XL ____ 2XL ____

12. Do you have any medical conditions we should be aware of?

______________________________________________________________________________
______________________________________________________________________________
How did you hear about the conference? _______________________________

Return application via fax at (602) 529-1310 or mail to PO BOX 924 Phoenix, AZ 85353

Omega Psi Phi Fraternity, Inc

OMEGA YOUTH LEADERSHIP CONFERENCE

WAIVER FORM
PARTICIPANT/MEDIA RELEASE
I hereby give my permission for (childs name) ____________________________
to participate in the Omega Psi Phi Fraternity, Inc.12th District Omega Youth
Leadership Conference. I also grant permission to record my child/wards
likeness and/or voice for use by television, film, radio, or print media to
further the aims of the organization in related campaigns, magazine articles,
booklets, posters, etc. I hereby release Omega Psi Phi Fraternity, Inc., 12th
District and Phi iota chapter, its insurer, agents, and heirs, from any and all
liabilities and claims in connection herewith.
CONSENT TO TREATMENT/EVIDENCE OF INSURANCE
In the event that my child/ward should for any reason require any medical
treatment and/or medication during the course of their attendance at or
participation in the Omega Youth Leadership Conference, I authorize such
physician or emergency care staff that the Omega Psi Phi Fraternity, Inc. may
appoint or designate to carry out necessary treatment, or take my child/ward
to the emergency room of any hospital, and I further authorize the hospital
and its medical staff to provide the treatment deemed necessary by them for
the well being of my child/ward. It is understood that I will be contacted, if
possible, by telephone and made aware of the nature of the situation.
I have read fully and understand the provisions of the above releases and
have explained them to the said minor. I hereby agree on behalf of myself and
my child to hold harmless and release the Omega Psi Phi Fraternity, Inc., from
any and all liabilities and claims arising out of any treatment rendered to my
child/ward.
EMERGENCY CONTACT NUMBER:___________________________________
PARENT SIGNATURE____________________________________________ DATE_____

FORM MUST BE SIGNED & RETURNED IN ORDER TO PARTICIPATE

Return application via fax at (602) 529-1310 or mail to PO BOX 924 Phoenix, AZ 85353