2023 Spirit of America – IX Partners October 26-29, 2023 Student Registration "*" indicates required fields 1Student2Medical History3Insurance Waiver4Parent5Talent Release6Honor Code Product ID is required. Please check the referring link. If you need assistance, please contact us. Freedoms Foundation Application Page for: From To Participant InformationName* First Last Date of Birth* MM slash DD slash YYYY Gender* Male Female Email* Home Phone*Cell PhoneHome Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Postal Code Personal InformationOrganizational MembershipsLeadership Positions HeldHobbies/Sports/TravelSchool InformationGrade*9101112Academic Ranking Top 10% Top 20% Top 30% Top 50% School/University* Principal/President Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Postal Code Parents/GuardiansYou must add at least one emergency contact for the applicant.Related Contact Name First Last Cell Phone*Email Relationship to ApplicantPlease select…FatherMotherParentAuntUncleGrandparentSpouseIs Emergency Contact? Yes No Add another Contact Add another Contact Related Contact Name First Last Cell Phone*Email Relationship to ApplicantPlease select…FatherMotherParentAuntUncleGrandparentSpouseIs Emergency Contact? Yes No Participant Medical InformationHeight Weight Most recent exam MM slash DD slash YYYY Most recent tetanus toxoid immunization MM slash DD slash YYYY Most recent COVID-19 vaccination MM slash DD slash YYYY Upload COVID-19 Vaccination CardMax. file size: 32 MB.Please provide any information about a student’s health history that may impact their participation in the program. This may include health concerns, food and medication allergies (see below), and/or current medications (see below).ConditionsNoneBleeding/Clotting disordersConvulsionsDiabetesFrequent ear infectionsHeart defect/diseaseHepatitisHypertensionMononucleosisAllergiesNoneAsthmaHay FeverInsect StingsIvy poisoning, etc.Other DrugsPenicillinImmunizationsNoneChicken PoxMeaslesMumpsRubellaDTaPFood AllergiesCurrent Medication TakingMedication AllergiesList any condition or illness that Freedoms Foundation should be aware of that is not mentionedDoctor's InformationDoctor's Name* Doctor's Phone*Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Postal Code SignatureParent or Guardian Signature* Insurance Waiver*Freedoms Foundation does not carry medical insurance to cover participants. All participating students should be covered by personal or family insurance. We (I) hereby certify, under penalty of perjury, that the above named student is covered by medical insurance. I agree to the Insurance WaiverParent or Guardian Signature*Names of Parents or Guardians* Insurance Company Policy/Group number Expiration Date of Insurance MM slash DD slash YYYY Insurance CardMax. file size: 32 MB.Either upload a copy of insurance card here or bring a copy with you to the program.Please list emergency number(s) other than those above at which parent, guardian, or another relative may be reached during the conference.Name PhoneName Phone Parent's Waiver*We (I) hereby give permission for the above named student to attend the Spirit of America Youth Leadership program on the dates listed above to be conducted at Freedoms Foundation at Valley Forge. We (I) hereby release and discharge the Freedoms Foundation at Valley Forge, its officers, agents, instructors and employees, from any and all claims, demands, suits, actions or causes of action which we (I) may or shall have reason of any illness, injury or accident incurred or suffered by the above named participant at this conference and in the course of travel by any means to and from and while on the premises of the Freedoms Foundation at Valley Forge, no matter how caused or occasioned. I agree to the Parent’s WaiverParent or Guardian Signature*Names of Parents or Guardians Parent/Guardian's Email Home PhoneCell Phone Talent Release*I, the undersigned, on behalf of my child listed above hereby grant absolute right and permission to Freedoms Foundation at Valley Forge to take photographs, video, verbal or written testimonials and/or audio reproductions of the person(s) named above and to copyright, use, publish, and distribute same. In granting such permission, I hereby relinquish any right, title or interest in such photographs, video, verbal or written testimonials, CD ROMs, DVDs, and/or audio reproductions and grant Freedoms Foundation at Valley Forge permission to publish, exhibit or use such audio/visuals for any and all promotional purposes stated, including but not limited to broadcast, website, social media, promotional videos, press releases, e-newsletters, and other print and/or electronic uses. I, the undersigned, certify that I am 18 years or older and have read this release and understand all its terms. I execute it voluntarily and with full knowledge of its significance. I agree to the Talent ReleaseParent or Guardian Signature* Honor Code*As a participant in the Spirit of America Youth Leadership Conference, I agree to: · Participate in all activities to the fullest extent possible. · Be on time to all scheduled events. · Show respect to my fellow participants, adults leaders, and myself. · Leave the campus — classrooms, dormitories, dining hall, etc — in the same condition I found them. · Follow all rules and instructions as communicated by the program director and staff. · Honor wake up time and lights out times. · Behave in a way that is always safe for me and others. · Make this weekend alcohol, tobacco, and drug free. I agree to the Honor CodeStudent Signature*EmailThis field is for validation purposes and should be left unchanged.
