2022-2023 IL HPP Student Leadership Committee Application

Thank you for your interest in the IL HPP Student Leadership Committee! We are excited that you want to be a leader in your school or community and influence the future programming of IL HPP.

By completing this paperwork, you are consenting to participation in the IL HPP Student Leadership Committee including but not limited to the meetings listed below. You are agreeing to attending at least three of the five total meetings scheduled for the IL HPP Student Leadership Committee.The first meeting will take place in a hybrid format, so you can attend both virtually or in-person at the OMNI Youth Services building at 1111 Lake Cook Road on Tuesday, October 18th from 6:45pm-8:15pm. Students who join this team and attend the first meeting will be in charge of creating a meeting schedule for the 2022-2023 school year. Information regarding meeting dates, times, and location will be shared as they become available. Additional activities may be included in the Student Leadership Committee calendar and attendance is optional.
Participant Information
Name:*
Date of Birth:*

MonthDayYear
Date
Gender:*
High School:*
Grade Level:*
Your t-shirt size:
What activities are you involved in (check all that apply):*

Academic ClubAthleticsMusic & Performing ArtsExtracurricular ClubsCommunity Volunteering
Why should you be selected to be a member of The Illinois Human Performance Project Student Leadership Committee? ( Can you share about a time when you were a leader or noticed that leadership would benefit your school? )
Contact Information
Participant Email Address:*
example@example.com
Participant Cell Phone:*
Yes, you can contact me for meeting reminders on my cell phone:*

YesNoNot yet: I have questions, please contact me
Participant Home Address:*
Participant's Parent/Guardian Name(s):*
Guardian Email Address:*
example@example.com
Guardian Cell Phone Number:*
Guardian Home or Work Phone Number:
Participant Medical Information
Are there any medical problems, disabilities, or disorders that we must be informed of? Please describe.*
Are there any medications being taken by the participant?*
Are there any allergies, dietary restrictions, or physcial limitations? Be specific (foods, medicines, animals, etc.).*
Emergency Notification
I authorize OMNI/ IL HPP staff or volunteers to contact the person(s) identified in the event of an emergency. I understand that such notification may necessitate that certain information regarding my condition or treatment be released, but only to the extent that said information is necessary to address the emergency. This consent will be in effect for the duration of my involvement with the IL Human Performance Project through OMNI Youth Services, but may be revoked or revised at my discretion through a written request delivered to the Program Director.

PERSON(S) TO BE CONTACTED IN THE EVENT OF AN EMERGENCY:
Primary Name & Relation to the participant:*
Primary Contact Home or Work Phone:
Primary Contact Cell Phone:*
Alternate Name & Relation to the participant:*
Alternate Contact Home or Work Phone:
Alternate Contact Cell Phone:*
Participant Signature & Date

Clear
Participant's Guardian Signature & Date

Clear
Consent for Services and Release of Photography/Video
I/We (guardian names),*
here by grant permission on behalf of (student participant name)*
to:

1. OMNI Youth services/IL Human Performance Project to provide my child prevention programming and services. I understand that such permission may be revoked, in writing, at any time. As an OMNI Youth Services/IL Human Performance Project service recipient, I have the right to refuse program services.

2. OMNI Youth Services/IL Human Performance Project to publish or release photographs or videotape of participant named above. Providing consent to OMNI Youth Services and the IL Human Performance Project for releasing photographs and/or videotape is voluntary and will not impact the services I am currently involved in, or may be involved with in the future. I/We understand that the photographs/videotape may be used for one or more of the following purposes: brochures/ publications, advertisements, flyers, grant reports, OMNI Youth Services and/or IL Human Performance Project web page and/or social networking sites, office reception areas, and promotional videotapes. If you are opposed to one or more of these uses for photo or videotape, check the box indicating so below and sign. This consent is subject to written revocations at any time except to the extent that release or publication has already occured. This consent must be revoked in writing to be considered invalid. I understand that these are photographs or videos that may be taken while I engage in OMNI Youth Services and/or IL Human Performance Project facilitated events. It is understood that a refusal to authorize the release of photographs/videotape will prevent disclosure to the person/organization identified above.
Check only if you do NOT consent to the above photography and video release listed in item 2, but still do consent to services as listed in item 1
Participant Signature & Date

Clear
Participant's Guardian Signature & Date

Clear
Release for Transportation
Whereas, blanks ( hereinafter called "Minor") is planning to participate in services provided by Omni/ IL HPP.
Whereas, Omni/ IL HPP Prevention Specialist, ( "driver" ) is planning on transporting minors in his/her personally owned car ( "transportation") and/or the Omni Owned van. blanks
Whereas, I the undersigned, have reached legal majority pursuant to the laws of Illinois and am parent or guardian to Minor; blanks
Now, therefore, in consideration of the Minor's availing him/herself of such transportation, and the personal nature of the services, I do hereby, on the behalf of the minor and on my own behalf remise, release and forever discharge Omni Youth Services and all of it's officers, agents, and employees, acting officially or otherwise, from any and all claims, demands, actions or causes of action on account of Minor's death or in account of injury to Minor which may occur from any cause during such outing or In the course of the transportation to and from such outing.
Name of Minor:
Participant's Guardian Signature & Date

Clear
Should be Empty:

Participant Information

Contact Information

Participant Medical Information

Emergency Notification

Consent for Services and Release of Photography/Video

Release for Transportation