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2023 Spirit of America – IX Partners

October 26-29, 2023

Student Registration

"*" indicates required fields

1Student
2Medical History
3Insurance Waiver
4Parent
5Talent Release
6Honor Code

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If you need assistance, please contact us.

Participant Information

Name*
MM slash DD slash YYYY
Gender*
Home Address*

Personal Information

School Information

Academic Ranking
Address*

Parents/Guardians

You must add at least one emergency contact for the applicant.
Related Contact Name
Is Emergency Contact?
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Related Contact Name
Is Emergency Contact?

Participant Medical Information

MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
Max. file size: 2 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).

Doctor's Information

Address*

Signature

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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.
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MM slash DD slash YYYY
Max. file size: 2 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.
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.
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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.
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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.
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This field is for validation purposes and should be left unchanged.
Freedoms Foundation of Valley Forge
  • P.O. Box 67
    Valley Forge, PA 19481
  • 1601 Valley Forge Road
    Phoenixville, PA 19460
  • 610.933.8825
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