Parent Approvals and Waivers
Unleash Your Greatness Youth Leadership Conference and Monthly Initiative
To Sign Your Name Type Your Full Name (First, Middle, and Last)
Sign in to Google to save your progress. Learn more
Child's Name *
Childs Age *
Parent/Guardian Full Name *
Parent/Guardian Phone Number  *
Parent/Guardian Email *
Relationship to Child *

I give permission for my child or student to attend and participate in Unleash Your Greatness Youth Resilience and Leadership Conference (Sunday June 25, to Wednesday June 28, 2022) Located at Houghton College in Houghton, NY.  

I release Duncan Kirkwood, Carolyn Kirkwood, Duncan Kirkwood Consulting LLC, Fostering Greatness, and all initiative sponsors and partners from liability for any injury or losses incurred by my child during the Unleash The Greatness student leadership conference and agree to indemnify the stated event partners against any expenses, loss or damages incurred as a consequence of any action or inappropriate inaction on the part of my child. I also confirm that I will disclose any pertinent medical information about my child or student on this form. 

(By typing my full name: (first, middle, last) below it is equated to a digital signature).

 *

Release of Liability

I have read and understood the above information and am signing this form to assure Duncan Kirkwood, and Fostering Greatness Inc. that parent/legal guardian and/or participant assumes all risks during the program.  *
Emergency Contact Name (If we cannot reach the parent/guardian) *
Emergency Contact Phone Number *

Please sign your name if you have received the packing list and understand that the below items must be brought by each participant.

(By typing my full name: (first, middle, last) below it is equated to a digital signature).

5 Pairs of socks

2 Pairs of sneakers (preferably black or grey and nothing really nice and new)

 4 PLAIN Black t-shirts

 2 Pair of PLAIN black or grey shorts to work out in

 2 Additional pair of PLAIN black shorts (any type basketball or cargo)

 Belt if young woman is bringing cargo shorts

3 bathing suits

 Toiletries: Tooth brush, tooth paste, lotion, and deodorant, sun screen if they use it

Any feminine products they may need

 *

Please sign your name if you understand that your student or child is not allowed to bring any contraband at all. This includes (but not limited to): Knives, vapes, cigarettes, weed, drugs of any kind that are not prescribed by a doctor, alcohol, weapons of any kind, box cutters, needles, tobacco products. 


(By typing my full name: (first, middle, last) below it is equated to a digital signature).

 *

Please sign your name to indicate that you understand that we will be taking the young women's phones. 

(By typing my full name: (first, middle, last) below it is equated to a digital signature).

 *

Please sign your name to indicate that you understand that students are not allowed to bring a tablet or laptop.

(By typing my full name: (first, middle, last) below it is equated to a digital signature).

 *

I grant permission to Duncan Kirkwood, Carolyn Kirkwood, Fostering Greatness Inc., Independent Health foundation, West Herr, National Grid, the City of Buffalo, Power 93.7 WBLK, and Beaver Hollow to use any photographs or videos taken of my daughter or student participant throughout the duration of the Unleash Your Greatness initiative. 

I hereby waive any right to inspect or approve the finished photos and videos that may be used now or in the future and I give consent for any and all photos and videos to be shared, publicized, or posted on social media for marketing and promotions. 

(By typing my full name: (first, middle, last) below it is equated to a digital signature).


 *
Young Woman's T-Shirt Size (in adult sizes) *
I give permission Duncan Kirkwood, Carolyn Kirkwood and trainers Leah Angel-Daniel and Taminka Mack to motivate, encourage, and operate in a drill sergeant/coach role with my child throughout the duration of the Unleash Your Greatness Initiative. 

(By typing my full name: (first, middle, last) below it is equated to a digital signature).

 *
My child or student has Asthma and uses an inhaler?   *
If "Yes" the child or student used an inhaler, I will make sure that they bring it with them to the Unleash Your Greatness youth leadership conference. 

(By typing my full name: (first, middle, last) below it is equated to a digital signature).
My child or student takes medication *
If "Yes" child or student takes medication, please indicate what type medication (if none type N/A) *
If "Yes" child or student takes medication, what are the times they take it? and doses? (If none type N/A) *
I understand that my child or students medication will be held by the conference trainers and given to the child or student at the time I have indicated. (If none type N/A)

(By typing my full name: (first, middle, last) below it is equated to a digital signature).
 *
Does the student have any allergies? If so what? *
If my child has allergies, I will make sure to send their EpiPen (if none type N/A).

(By typing my full name: (first, middle, last) below it is equated to a digital signature).
 *
In the event of a medical emergency, I understand that my child will be taken to the nearest hospital for treatment and/or care immediately. 

(By typing my full name: (first, middle, last) below it is equated to a digital signature).
 *
I understand that the emergency contact for Unleash Your Greatness student leadership conference is Carolyn Kirkwood (conference director) and can be reached at 716-390-5598 or email LynnHutchen56@gmail.com 

(By typing my full name: (first, middle, last) below it is equated to a digital signature).
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms