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Emergency Contact Information
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Second Phone Number
Alt. Emergency Contact
Date of Birth
How did you find out about Global Leaders
Has the applicant been seriously injured in the last year and required medical treatment? Please explain.
Please list any known food, medical, or other allergies.
Please list ALL over-the-counter and prescribed medications this participant will be bringing with them.
Please note any accommodations you need for religious/spiritual worship.
Dietary Needs (Select All that Apply)
Celiac Diet (Gluten-free)
Please note any language assistance you might need.
Please note any physical/mental/emotional accommodations you might need.
Please check/list any current medical conditions
Other (note below)
I can afford the entire $300:
I need Financial Aid
I can afford to pay:
While attending Global Leaders, the Applicant is covered by the Inclusion Center's accidental secondary insurance. This will provide supplementary coverage to your primary insurance.
Does the participant have medical/hospital insurance?
Policy Holder Name
Holder ID #
In the event of an accident or illness which requires emergency medical care, I understand that every effort will be made to contact guardians of the individual involved. In the event that I cannot be reached, I give my permission to the Inclusion Center to transport my dependent to appropriate medical facilities as needed for licensed nurses and/or physicians to order such medical attention as may be deemed necessary for my dependent's health and safety. I consent and agree to the emergency release terms mentioned above.
I understand that my dependent's image and/or personal statements might be publicized and/or used by the Inclusion Center and/or its approved partners. I also give permission for my dependent's information (address, phone, email, and school) to be printed on the contact roster for other participants and staff to access after the retreat.
I DO consent and agree to the terms above.
I DO NOT consent and agree to the terms above.
I agree to be present fore the ENTIRE program and agree to have respectful and responsible behavior while there.
I understand that CELL PHONES ARE NOT ALLOWED.
In case of an emergency, my family may contact the Inclusion Center staff at 801-367-1974 (Cameron’s Cell) or 801-652-1918 (hande’s Cell) and they will relay the message to me.
I understand that no activities are to be engaged in that will endanger other participants or cause damage to the place of training.
I understand that I may NOT use Inclusion Center programming or materials outside of the Event.
I understand that I may NOT bring any weapons.
I understand that I may not bring or use any drugs, alcohol, or cigarettes at the Event.
I understand that I will be required to turn in ALL medications to the medical staff to be distributed by them.
I understand that I may NOT engage in any sexual activity while at the Event.
I understand that I will be required to pay for any damages to the facility for which I am responsible.
I understand that, if I fail to follow any of the abovementioned statements, I may be dismissed from the program.
I understand that my dependent’s participation in an Inclusion Center event or program exposes him/her to risks inherent in camping and youth events.
I hereby acknowledge and agree to assume any such risks.
I understand that the Event is an intensive human relations program that deals with mature subject matters.
I understand that workshop topics may include value-clarification, self-esteem, stereotypes, prejudices, interpersonal communication, racial identity, racism, sexism, sexual orientation, classism, family issues, institutional and personal power, and more.
Throughout the week, students may experience confusion, anger, joy, sadness, frustration, hope, and more as they learn.
I assure you that my child is capable of handling the subject matter and emotional nature of this program.
In consideration of being permitted to participate in the event, I hereby agree that for my dependent, I shall hold harmless the Inclusion Center and/or its board members, employees, agents, licensees, and volunteers from any and all claims, demands, actions, or suits arising out of or in connections with my dependent’s participation in the Event, including those claims which may arise from the negligence of the Inclusion Center, its board, employees, agents, licensees, and volunteers.
I acknowledge that the health history is correct and complete as far as I know and the person herein described has permission to engage in program activities, except as noted.
If my dependent’s medical information should change prior to the program, I will notify the Inclusion Center of any new conditions, medication, limitations, etc.
I understand that CELL PHONES ARE NOT ALLOWED.
In case of emergency, I may contact the Inclusion Center at 801-367-1974 or 801-652-1918 and they will relay the message to the applicant.
14 Heritage Center
Salt Lake City, Utah
Inside the Equity Office
Ground Floor of Building 820
University of Utah