2025Teen Leadership Summit Registration Form

SECTION 1 - Student Information

Name

First

Last

Nickname/Preferred

Date of Birth (mm/dd/yyyy)

Gender

What are your preferred pronouns?

she/her/hers
he/him/his
they/them/theirs

Address

Address Line 1

Address Line 2

City

State

Zip Code

School Name

Email (Teens)

Year of High School Graduation

SECTION 2 - Parent/Legal Guardians Information

Guardian #1 Information

Name (Guardian #1)

First

Last

Email

Phone

Guardian #2 Information

Name (Guardian #2)

First

Last

Email

Phone

SECTION 3 - Emergency Contact

Name

First

Last

Phone

Relationship to Teen

SECTION 4 - Health History

If Parent/Legal Guardian is unavailable, who else should we contact in the event of an emergency?

Does the student have any allergies?

Yes
No

For the medication questions below, provide complete information. Bring enough medication to last the entire session(s). ALL medications MUST be in original pharmacy containers and appropriately labeled. Participants should be taking the same medication at the same dose for at least three months prior to arrival. All medications (including over-the-counter) must be checked into the Health Center.

Does the student take any medication?

Yes
No

The student/registrant's Pediatrician

The student/registrant's Pediatrician Phone Number

SECTION 5 - Additional Medical Information

Is there any other medical information you would like to share with us about your child? Please write any additional doctors with phone numbers that your child sees.

Does the registrant/student need any special assistance (ADA, etc.)?

Yes
No

Do you give the nurse/staff permission to give the registrant/student:

Tylenol
Advil
All of the above
None of the above

SECTION 6 - Release Signatures

Emergency Transportation Release

I agree to the terms below.

I hereby grant Teen Health Connection, a North Carolina not-for-profit corporation, or its designee the right to transport the above captioned minor to any emergency medical or healthcare facility for immediate treatment and/or consultation, if necessary. Further, I hereby grant Teen Health Connection, or its designee, the right to consent on behalf of the above captioned minor for medical treatment. I understand that I will be notified of any emergency situation as soon as reasonably practical, but that this Emergency Medical Release may be utilized in the event that I am unavailable to provide necessary consent, and immediate authorization for treatment is required. This release is effective for Teen Health Connection's Empower: Teen Leadership Summit until November 5th, 2024

Rules & Regulations

I agree to the terms below.

These rules are designed to ensure that all participants at Teen Health Connection's Empower: Teen Leadership Summit enjoy a maximum learning experience in an environment conducive to the exchange and sharing of ideas and concepts. All participants are expected to adhere to the rules as outlined herein, or may be established from time to time by Teen Health Connection. Any violation of these rules may result in either a private discussion with a member of the Teen Health Connection staff or immediate removal from the program or event. Enforcement and supervision of these rules shall be at the sole discretion and judgment of Teen Health Connection. Parents/Legal Guardians will be responsible for transportation if their teen is removed from the Summit. All expense or cost associated with the participant’s removal from the program shall be the responsibility of the participant’s parent/legal guardian.

Photo/Video Release

I agree to the terms below.

I understand that pictures and/or videos of my child may be taken at the Summit and hereby agree and consent to the use of these pictures and videos by the Empower: Teen Leadership Summit or its sponsoring organization Teen Health Connection for promotional or any other purpose.

If you have questions about photo/video consent, please address them with your Teen Health Connection representative.

Evaluation Release

I agree to the terms below.

I give permission for my child to complete the Empower: Teen Leadership Summit evaluations. I also give my permission for my child to participate in post-Summit surveys and evaluations. I understand that the data collected will be used for future program development..

Registration Fee

Price: $25.00

When you click submit you will be taken to PayPal to complete the registration fee. Your registration is not considered complete until the registration fee of $25 is received.

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