2022 KBG Summer Strategic Planning Retreat

Activate for a Tobacco-Free '23

2023 KBG Youth Summit
Registration Type*
How did you hear about the event?

Your Information

Please complete all sections below.
Your Name*

First NameLast Name
Your Email (Students: Do NOT your student school email. Adults: you may use your school email address.)*
example@example.com
Parent/Guardian Name

First NameLast Name
Parent/Guardian Email*
example@example.com
Your Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School/Organization*
Your Grade*
Are You a Current KBG Force Captain?*
Your Shirt Size*
Your Sweatshirt Size*

Transportation
Will you need transportation to get to and from the event?*
Which location is closest/easiest for you?*

Your Medical Information

Please provide details below.
Do you have any medical conditions or needs we need to be aware of?*
Please describe, in detail, your medical conditions or needs below.
Do you have any dietary or food restrictions we need to be aware of?*
Please describe, in detail, your dietary or food restrictions below.
If applicable, include any other important details you believe the event staff should know.

Emergency Contact Information

Please provide 2 emergency contacts below. This can be your parent/guardian.
Emergency Contact #1 Name*

First NameLast Name
Emergency Contact #1's Relationship to You*
Emergency Contact #1's Relationship to You*
Emergency Contact #1's Phone Number*
Please enter a valid phone number.
Emergency Contact #2 Name*

First NameLast Name
Emergency Contact #2's Relationship to You*
Emergency Contact #2's Relationship to You*
Emergency Contact #2's Phone Number*
Please enter a valid phone number.

KBG Code of Conduct

Please review the following information. Once you have read the information below, you will be able to provide your signature. Parents and Guardians will sign along with their youth.
KBG Code of Conduct:

WHEREAS, the possession and/or use of weapons, tobacco products, alcoholic beverages and illegal drugs, or remaining in the presence of individuals who are using or taking these items is prohibited

WHEREAS, sexual contact or sexual harassment at any event or activity which occurs within the frame of the KBG/ALA Event is prohibited

WHEREAS, any behavior that violates any of the laws of the United States or the State of Delaware or any local ordinance is also prohibited

WHEREAS, any youth exiting the facility housing the workshop or overnight accommodations will be sent home at the expense of my parent/guardian

WHEREAS, any youth driving to the workshop will not be permitted to use the vehicle until the designated time of departure.

WHEREAS, all participants are expected to show respect for the property of others and the facility in which all events will be held.
By signing below, I (YOUTH) have read and agree to follow the KBG Code of Conduct as stated above.*

Clear
By signing below, I (PARENT/GUARDIAN) have read and agree to follow the KBG Code of Conduct as stated above.*

Clear

The following sections are for parents/guardians only.
KBG Medical Consent:

Being a person authorized by law to give such permission, do thereby give my permission for emergency medical treatment to be given to the person who is the above registered and the named subject of this form. I understand that all reasonable attempts will be made to contact me as soon as possible after the condition necessitating treatment arises, and that failing to reach me, all reasonable attempts to contact the alternate listed will be made. I understand that all reasonable precautions will be taken for safety at all times. I further release the KBG, the American Lung Association of Delaware and all persons associated with this organization from any liability associated with any accident, injury or disease the person who is subject on this from.
By signing below, I (PARENT/GUARDIAN) have read the medical consent above and give consent to the KBG and American Lung Association to provide medical treatment to my child, if necessary. *

Clear
Media Consent

Due to the nature of the activities of the tobacco prevention event, your child may have the opportunity to appear on TV, be interviewed by radio/ newspaper reporters or have his/her picture on the sponsoring organization’s web site.
I (PARENT/GUARDIAN) have read the KBG Media Consent as stated above and*
Parent/Guardian Signature for KBG Media Consent Decision *

Clear
Informed Consent and Release

I understand the nature of the program and give my permission for my son/daughter’s voluntary participation in the KBG/ALA tobacco prevention event. I release the sponsoring organization from any liability involved from my son/ daughter’s involved from my son/daughter’s participation in this program.
Parent/Guardian Informed Consent and Release Signature*

Clear

Adult Advisor/Chaperone Consent
KBG Medical Consent:

In the event of an emergency, I do hereby give my permission for emergency medical treatment to be administered to me. I understand that all reasonable attempts will be made to contact my emergency contacts as soon as possible after the condition necessitating treatment arises. I understand that all reasonable precautions will be taken for safety at all times. I further release the KBG, the American Lung Association of Delaware and all persons associated with this organization from any liability associated with any accident, injury or disease the myself who is the subject on this from.
By signing below, I have read the medical consent above and give consent to the KBG and American Lung Association to provide medical treatment to me, if necessary. *

Clear
Media Consent

Due to the nature of the activities of the tobacco prevention event,I may have the opportunity to appear on TV, be interviewed by radio/ newspaper reporters or have his/her picture on the sponsoring organization’s web site.
I have read the KBG Media Consent as stated above and*
Signature for KBG Media Consent Decision *

Clear
Informed Consent and Release

I understand the nature of the program and I am voluntarily participating in the KBG/ALA tobacco prevention event. I release the sponsoring organization from any liability involved from my involvement from my participation in this program.
Informed Consent and Release Signature*

Clear

Submission
Do you have any other comments, questions, or concerns? If so, please enter below and then click SUBMIT to complete your registration. If you do not have any additional comments to add, please click SUBMIT to complete your registration.
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Activate for a Tobacco-Free '23

Your Information

Transportation

Your Medical Information

Emergency Contact Information

KBG Code of Conduct

The following sections are for parents/guardians only.

Adult Advisor/Chaperone Consent

Submission