Striving for Success: The African American Male Summit

Striving for Success is a day-long event that inspires 9th grade African American males to excel in their education and in the community. Attendees will have the opportunity to meet and hear inspiring stories from successful African American professionals through various break-out sessions. The event is free to attend. Transportation and lunch are provided.

2023 Registration form

"*" indicates required fields

Student Information

Student's Full Name*

First Last

Preferred Name*

Preferred Name

High School as of August*

Other:

Address*

Street Address Address Line 2 City State ZIP Code

Student Email*

Student Cell Number*

Student ID# (if available)

Parent/Guardian Information

Parent/Guardian's Full Name*

First Last

Parent/Guardian's Daytime or Cell Phone*

Parent/Guardian's Email*

Medical Information

Is youth currently taking any medication?*

Yes

If yes, please explain:

Is there any medical matter that Summit staff should be aware of?*

Yes

If yes, please explain:

Emergency Contact*

First Last

Emergency Contact Phone*

Relationship to Student*

Meal

Meals for the entire day are included. Does the student have any special dietary needs and/or food allergies?*

Yes

If yes, please explain:

Parent/guardian authorization

As the parent/guardian of the above-listed student, I...

Acknowledge that the information provided is correct to the best of my knowledge. If there is a change in information, I will notify the Striving for Success Summit staff.*

Give permission to my child (listed as student) to attend the Striving for Success Summit and participate in all event-related activities unless otherwise noted.*

Give permission for medical attention to be sought in case of an emergency. Summit Staff will attempt to reach parent/guardian and emergency contact prior to seeking medical attention.*

Give consent for Striving for Success Summit staff to reach out to my student via text or email to relay event information.*

Parent/Guardian’s Signature*

First Last

Date*

MM slash DD slash YYYY

Relationship to Student*

Media Consent

Media Consent*

YES, I give the partners and sponsors of the Striving for Success Summit the right and permission to use photographs, artwork and/or videos of my child or those in which they may be included as a group. I understand that photos and videos may be used in print, video, and on social media, including the internet. I waive any right to inspect or approve the finished product or products or the advertising copy or printed matter that may be used with the finished media. I hereby release and discharge The Urban League of Nebraska from any and all claims and demands ensuing from or in connection with the use of the photographs and/or videos, including any and all claims for libel and invasion of privacy. This authorization and release shall inure to the benefit of the legal representatives, licenses and assigns of Striving for Success partners and sponsors as well as the person(s) for whom they took the photographs and/or videos. I represent that I am the parent/guardian of the child listed above and hereby consent to the foregoing on their behalf.

NO, the sponsors and partners of Striving for Success Summit do not have permission to utilize photographs or videos of my child.

Summit Covenant

Summit Covenant*

I acknowledge and accept in writing that the Striving for Success: African-American Male Summit based upon mutual trust, respect for others and adherence to the spirit and following set of standards:*

· I will respect all others and their possessions.
· I will treat all Summit Staff and volunteers with respect and will treat all buildings and furnishings with care.
· I will adhere to the rules of First Student (transportation company) to and from the Summit.
· I will remain on the Summit site throughout the conference unless accompanied by an adult staff member designated by the conference coordinators.
· I acknowledge that some of the group discussions may cover mature matter subject matter (i.e. youth violence, etc.)

Attending the Striving for Success Summit is a privilege. Participants are encouraged to enter fully and cooperatively. Summit staff reserves the right to terminate participation in the conference of anyone whose conduct is considered detrimental to the Summit community.

Student Participant's Signature*

First Last

Date*

MM slash DD slash YYYY

Parent/Guardian’s Signature*

First Last

Date*

MM slash DD slash YYYY

Phone

This field is for validation purposes and should be left unchanged.

Questions?

Contact Megan Moslander at megan.moslander@urbanleagueneb.org with any comments or questions.