Theme: Control Your Destiny or Someone Else will

PARENT/PARTICIPANT RELEASE FORM

I  _______________________________  (Parent or Legal guardian) understand that the participation of
  __________________________________ (Participant) in Omega Educational Foundation’s 16th Annual Youth Leadership Conference.  The events of the Youth Leadership Conference will be in a classroom setting. Omega Educational Foundation will bear the full cost of food for each participant in the event.

 Parent /Guardian must provide Transportation to and from the 16^th Youth Leadership Conference.

I understand that signing this release form is an acceptance to the above and a prerequisite to participate in the 16^th Annual Youth Leadership Conference.  In addition, it is your responsibility to inform the Program Coordinator of this program of any extenuating circumstances (medical, physical, diet, or mental) that affects the well-being of the participant or might detract from learning experiences of the other participants.   Parents and Guardians are also responsible for ensuring each participant has no weapons, drugs, or any illegal substance that causes threat to him or the general body of   participants.

Signed: _____________________________________________ Date:____________________________

                     (Parent or Legal Guardian)

Print Below:

Name of Parent or Legal Guardian:________________________________________________________             

Address:______________________________________________________________________________

City, State, Zip:  ______________________________________________________________________

Home Phone Number:___________________________________ Cell #__________________________

E-mail Address: ___________________________________________________________________

Emergency Phone for Day of the Event: ____________________________________________________

PLEASE LIST ANY ALLERGIES, DIETARY RESTRICTIONS, OR MEDICAL CONDITIONS YOUR CHILD HAS:_______________________________________________

Please return to the address below:

Omega Educational Foundation

16th Annual Youth Leadership Conference

P.O. Box 91302

Los Angeles, California  90009

Please contact Ricky L. Lewis (323) 658-2995 or  rickylewis@earthlink.net  if you have any questions.