form-2023 – Enterprise Leadership Conference

Application Form

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Signed By Student

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Signed By Parent

Name(Required)

Email(Required)

Phone(Required)

Gender(Required)

Select School(Required)

School Name(Required)

Street Address(Required)

Box/Suite Number

City(Required)

State(Required)

Zip Code(Required)

Parent/Guardian Details

Parent/Guardian's Name(Required)

Parent/Guardian's Email(Required)

Parent/Guardian's Relationship(Required)

Parent/Guardian's Phone(Required)

Parent/Guardian's Rotary Affiliations/Club

Do you know any Rotarians? If so, please state their name, relationship to you and club to which they belong. How has this relationship affected your interest in ELC? (50 words max.)

Medical Insurance Provider(Required)

Policy Holder Name(Required)

Group Number(Required)

Medical Insurance Member ID(Required)

Medication

Allergies

Dietary requirements/Food allergies

Are you a member of “Interact” at your high school?

If yes, state for how long and if any leadership roles you have had. Share how your involvement with Interact has influenced you. (50 words max).

What makes you interested in applying to this conference? (200 words max)(Required)

Tell us something interesting about yourself(Required)

In 10 years, what do you see yourself doing? (200 words max)(Required)

Please provide a name and email address for your teacher or school representative so they may upload your letter of recommendation(Required)

Name(Required)

Student needs to sign.

Authorization, Consent and Release Form

Thank you for submitting your application to ELC. Please review the information below, and then date and DocuSign at the bottom of this page.

This authorization and consent release pertain to the Enterprise Leadership Conference taking place between 3/12/2025 to 3/14/2025

1. Confirm that I have received, read, and understood the contents of the Rotary Expectations of Accepted Students (available at https://www.rotaryelc.org/) and that the information provided in this application is accurate at the time of signature.

2. Confirm that I understand the nature of the ELC experience and the requirements for the applicants’ participation.

3. Confirm that the I am available to participate on all stated dates for the Enterprise Leadership Conference.

4. Confirm that I am now a high school junior in credits and expect to be a high school senior in the fall following the event.

5. Grant to The Rotary Club permission to copyright, use, reuse, publish and republish any photograph/ video taken of the student by The Rotary Club or those commissioned by The Rotary Club. This right applies to any reproductions in any form, used alone, in a composite or with any printed matter or advertising copy, for any purposes of trade, advertising, publicity, promotion or education, without restrictions or limitations. I release The Rotary Club and its agents from liability resulting from any distortion, blurring, alteration, optical illusion, or placement in a composite, intentional or otherwise, which may occur in the taking, processing, reproduction, publication, or distribution of such image(s). I waive the right to approve the image(s) or use. I have read this agreement and release all liability and understand the terms.

6. Grant to The Rotary Club permission to share my e-mail address with other event participants for the purpose of preparation and team building. I understand that this information will not be sold or used in relation to any commercial activity.

7. Acknowledge the requirement to attend the Orientation session and agree to do so.

Student Consent and Waiver

With my signature, I hereby:

1. Acknowledge and agree to the points outlined above.

2. Confirm that I will abide by the Rotary Expectations of Accepted Students and will conduct myself in a manner that will bring positive credit to my school, my parents, the sponsoring Rotary Clubs, and me.

3. Agree that once I am signed into the Conference, I will not leave without the permission of the ELC Chairman and the permission of my parents.

Signature(Required)

Date(Required)

Parent needs to sign.

Authorization, Consent and Release Form

This authorization and consent release pertains to the Enterprise Leadership Conference taking place between 3/12/2025 to 3/14/2025

With my signature, I hereby:

1. Acknowledge and agree to allow my child to apply to Enterprise Leadership Conference in accordance with the Rotary Expectations of Accepted Students (available at https://www.rotaryelc.org/)

2. Confirm that I am the legal parent/guardian of the applicant, and that I am listed as the primary contact in this application

3. Authorize, in the event of emergency, the bearer of this form to request, obtain, contact, or direct the provision of medical care for the named, student should this be necessary during the period of the Enterprise Leadership Conference activities. I accept all financial responsibility for such medical care as may be rendered.

4. Consent and grant the applicant permission to attend and be transported by the Rotary Clubs’ Enterprise Leadership Conference during the event.

5. In consideration of the selection of said student for participation in the Conference activities and the education, training, recreation and fellowship afforded thereby, I, for myself, heirs, executors, administrators, and assigns, hereby waive and release all rights and claims against the Rotary Club, their officers, agents, employees, representatives, members, successors, and assigns for any damages or injuries which may be sustained by said student in connection with or for participation in the Enterprise Leadership Conference.

6. Consent to allowing the information in this application to be shared with other local Rotary Clubs if the applicant is not selected for this event.

7. Acknowledge the requirement to attend the Orientation session and agree to do so.

Signature(Required)

Date(Required)

Student Name

Teacher Name

Teacher Email