Group Registration

IF YOU DO NOT HAVE AT LEAST 10 YOUTH IN YOUR GROUP, PLEASE DO NOT USE THE GROUP REGISTRATION!
THE GROUP REGISTRATION IS FOR THOSE REGISTERING 10 OR MORE STUDENTS AT A TIME.
PLEASE USE THE INDIVIDUAL REGISTRATION IF YOU ARE REGISTERING LESS THAN 10 YOUTH!

Name of Organization *

Organization's Representative *

Address: *

Street AddressCityStateZip Code

E-mail: *

Phone: *

-
Area Code	Phone Number

Contact Person: *


First	Last

Each organization may register up to 40 students grades 6-12 only. Please provide the names, grade and gender of each participant attending in the spaces below. If your overall number drops, please let us know immediately so other youth can fill the available spaces.

Participants Information

1. Name *

1. Grade *

1. Gender *

2. Name *

2. Grade *

2. Gender *

3. Name *

3. Grade *

3. Gender *

4. Name *

4. Grade *

4. Gender *

5. Name *

5. Grade *

5. Gender *

6. Name *

6. Grade *

6. Gender *

7. Name *

7. Grade *

7. Gender *

8. Name *

8. Grade *

8. Gender *

9. Name *

9. Grade *

9. Gender *

10. Name *

10. Grade *

10. Gender *

Staff Information: (3 staff members must accompany every 20 students.)

Staff 1: *

Staff 2: *

Staff 3: *

How did you hear about the conference? *

By submitting pre-registration, you agree to the following terms and conditions:
Release of Liability: I hereby give permission to the above child (rens) to participate in Teen Graffiti’s “Keepin’ It Real” Youth Empowerment Summit sponsored by Teen Graffiti Magazine, Teens Reaching Teens, Incorporated, Dallas County Community College District and Mountain View College. I hereby irrevocably and unconditionally release, discharge, and waive any and all claims or causes of action of any nature now or hereafter existing, whether known or unknown, against Teen Graffiti Magazine, Teens Reaching Teens, Incorporated, Dallas County Community College District and Mountain View College, their agents, employees, officers, or representatives from any and all responsibility for any injuries or damage sustained by me my child or family, arising from any act or omission, negligent or otherwise, of Teen Graffiti Magazine, Teens Reaching Teens, Incorporated, Dallas County Community College District and Mountain View College, their agents, employees, officers, or representatives in connection with Teen Graffiti’s “Keepin’ It Real” Youth Empowerment Summit.

Medical Waiver: In the event of an emergency, I DO grant permission to Teen Graffiti Magazine, Teens Reaching Teens, Incorporated and Mountain View College/Dallas County Community College District to transport my child/ward to a hospital/afterhours clinic for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. As the parent/legal guardian, I give full authorization to Teen Graffiti Magazine, Teens Reaching Teens, Incorporated Program staff or agents and Mountain View College/Dallas County Community College District and its employees, agents and/or subcontractors to secure medical care or treatment for above named youth(s). This treatment may include assistance from the nearest physician, medical clinic, hospital, trained nurse or EMT in the event of illness or injury that requires immediate attention, as determined by the event staff. In the event that I cannot be contacted, and an emergency has occurred, I give permission to the treating medical institution and/or medical providers to hospitalize and administer the appropriate treatment deemed medically necessary. I further agree that Teen Graffiti Magazine, Teens Reaching Teens, Incorporated and Mountain View College/Dallas County Community College District and its employees and agents will not be held responsible for injuries or damages arising from the provision of any such emergency medical treatment. I understand that as a parent/legal guardian, I will be responsible for the cost of any service or treatment provided. This authorization shall remain effective until he/she completes their activities in this program. I have read this document, I understand its contents, and I agree to its terms.

Publication Consent: This form is used to obtain permission for Teen Graffiti Magazine, Teens Reaching Teens, Inc., Dallas County Community College District and Mountain View College to use volunteers, students and parents or any other participants attending Teen Graffiti’s “Keepin’ It Real” Youth Empowerment Summit artwork, photographs, website and/or statements in publications, media releases and/or information display.

Organization's Representative registering Group *

Today's Date: *