PowerUp Youth Leadership Application

Student Email Address

Student Phone Number

Parent(s) or Guardian(s) Names

Parent(s) or Guardian(s) Phone

Emergency Contact (other than parent/guardian)

Emergency Contact Phone

Any medical condition(s) we should be aware of

STUDENT

As the participating student, I agree to follow these rules:

I will remain in the designated area and will not leave the premisis unless arrangements are made with West River Electric staff and my parents.

I understand that no alcoholic beverages or illegal substances will be allowed. If I am on medication prescribed by a physician, I will inform West River Electric staff.

I will keep my cell phone silenced during the sessions.

I understand that I have to complete/take part in all required activities to be eligible for trip and scholarship awards.

I understand that to receive a scholarship, I must attend a post-secondary school upon high school graduation.

By entering an event or program at West River Electric, you are entering an area where photography, audio and video recording may occur. Your entry and presence on the event premises constitute your consent to be photographed, filmed, and/or otherwise recorded and to the release, publication, exhibition, or reproduction of any and all recorded media of your appearance, voice, and name for any purpose whatsoever in perpetuity in connection with West River Electric and its initiatives, including, by way of example only, use on websites, in social media, news and advertising. By entering the event premises, you waive and release any claims you may have related to the use of recorded media of you at the event, including, without limitation, any right to inspect or approve the photo, video or audio recording of you, any claims for invasion of privacy, violation of the right of publicity, defamation, and copyright infringement or for any fees for use of such record media. You understand that all photography, filming and/or recording will be done in reliance on this consent. If you do not agree to the foregoing, please do not enter the event premises.

Student Signature

PARENT/GUARDIAN

My child has permission to attend and participate in all activities during PowerUp Youth Leadership Program sponsored by West River Electric Association. I understand that if my child does not adhere to the above rules, I will be called to come pick my child up from any activity. I also understand that if my child does not adhere to the rules and requirements of the program, they may not be eligible for trip and scholarship awards.

Parent/Guardian Signature

Please give a short essay answer to the following question: "Who in your life do you view as a leader and why?"

How did you hear about the PowerUp Youth Leadership Program?

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Pay By Phone: 605-791-6555