LITE Event Registration

Please type the name of the event for which you are registering. *

Name *

First

Last

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Your Birth Date (month, day, year) *

Please identify your gender *

Male
Female
Non-binary
Decline to answer

Please identify your race. *

Please check ethnicity. *

Hispanic origin
Not Hispanic origin
Decline to answer

How are you participating in this event? *

Youth worker
Enrolled in LITE services
Not enrolled in LITE service, yet

If not enrolled as a LITE participant, are you with an organization? Please provide the name of the organization below.

What do you hope to get out of participating in this event?

How did you hear about this event?

Consent for Promotional Purposes - permission to Leaders In Transformational Education (LITE) to use artwork, writing or pictures/videos taken at this event for the promotional purposes. I understand that refusal to sign this release will not affect delivery of service in any way. I am 18 years old or older/ I am a parent or guardian of a child under 18 years of age *

Consent
No Consent

All participants must Sign: I understand and agree to any policies, notices, and procedure regarding the COVID Pandemic and I will contact LITE coaches immediately if I or someone I may have been in contact with is diagnosed with COVID within 14 days of this event. *

I/my child does not have a medical condition that I am aware of that prevents me / my child from participating in this activity. I agree to hold Leaders In Transformational Education (LITE) and any of its officers, employees, or volunteers free from any and all liability and waive all claims of damages or recompense for any accident, injury or disability to me or my property arising out of or connected with my participation in this activity/outing. I also authorize the Chief Executive Officer of (LITE), or duly designated representative, to secure the necessary medical, hospital and surgical attention, in the event of illness or physical injury to me/ my child during participation in this activity. By providing your signature below you have read and agree to the statement above. *