2014 STUDENT REGISTRATION FORM

Youth Initiative & College Initiative Korean-American Student Leadership Conference

 

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APPLICATION INSTRUCTIONS: • Fill out this Registration Form in its entirety and attach your answers to the short essay questions. Additional

copies can be downloaded at www.yiconference.org. • You, your Parent/Guardian (if under 18 years old), and Pastor must all sign and date this Registration Form,

including the Liability Release. • Mail and/or Fax this Registration Form, your answers to the Short Essay Questions, Liability Release, and

Registration Fee to: Youth Initiative/College Initiative Fax – 1-888-634-4205 c/o Minnie Lee 10748 Ellicot Way Alpharetta, GA 30022 • All registration fee checks for both YI and CI should be made out to “Youth Initiative”. There is a $35 fee for

bounced checks. • Registration Fees are non-refundable, but transferable to another participant within the same church for the

same conference year only. • There will be a “no-show” fee of $200 for those who register but do not come to the Conference. • You may submit payment by mailing a check or using a credit card online at www.yiconference.org/register. • Please contact the Program Directors for questions regarding each conference. Youth Initiative Gloria Kim 678-925-3415 yiconference.programdirector@gmail.com College Initiative Daniel Cho 646-808-6336 ciconference.programdirector@gmail.com

APPLICATION DEADINE:

• Early Bird Registration $325 registration fee Postmarked by 5/10/14 • Regular Registration $400 registration fee Postmarked by 5/31/14 • In order to finalize registration and housing numbers, registrations postmarked after 6/1/14 cannot be

guaranteed admittance to the Conference. PERSONAL INFORMATION: I am attending as a: YI Student CI Student FIRST AND LAST NAME DATE OF BIRTH (MONTH/DAY/YEAR) AGE HOME STREET ADDRESS CITY STATE ZIP YOUR CELL # PARENT/GUARDIAN NAME & CELL # EMERGENCY CONTACT NAME RELATIONSHIP TO YOU EMERGENCY CONTACT PHONE #

M F XS S M L XL EMAIL ADDRESS SEX T-SHIRT SIZE SCHOOL NAME CITY STATE

10 11 12 1ST 2ND 3RD 4TH 5TH GRADE/YEAR IN COLLEGE (AS OF FALL 2014) ANTICIPATED GRADATION MONTH/YEAR

Y N YI CI HAVE YOU ATTENDED THE YI/CI CONFERENCE BEFORE? IF YES, WHICH CONFERENCE? WHICH YEAR?

CHURCH INFORMATION: CHURCH NAME CITY STATE PASTOR NAME PASTOR CELL #

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TRAVEL INFORMATION: * If you do not know your travel information at the time of filling out this Registration Form, please be sure to email your travel information to Minnie Lee at minnie812@gmail.com once you book your flight. You may also submit your travel information online at www.yiconference.org/register. How will you be getting to the conference? By Car/Bus By Airplane ARRIVAL DATE AIRLINE FLIGHT # ARRIVAL TIME DEPARTURE DATE AIRLINE FLIGHT # DEPARTURE TIME

MEDICAL INFORMATION: Do you have health insurance? No Yes (Please fill in information below and attach a copy of the FRONT AND BACK of your health insurance card to this Registration Form.) INSURANCE COMPANY NAME POLICY HOLDER NAME & CELL PHONE POLICY/MEMBER # GROUP # INSURANCE COMPANY PHONE # LIST ANY & ALL SPECIAL MEDICAL PROBLEMS, FOOD/DRUG ALLERGIES, AND DIETERY NEEDS LIST ANY & ALL MEDICATIONS THAT WILL BE TAKEN DURING THE CONFERENCE SHORT ESSAY QUESTIONS: Please answer each of the following questions and attach them to this Registration Form. Please answer each question thoughtfully and thoroughly in at least 5 sentences.

1. Describe your life before Christ, your acceptance of Christ, and how your life changed after you accepted Christ.

2. What are your current role(s) and/or past role(s) in your church? 3. Describe the leader that inspires you most. Why does this leader inspire you? 4. What do you hope to obtain from this leadership conference?

LINENS (OPTIONAL): The Conference WILL NOT be providing linens (towels, bed sheets, blanket, pillow) so please remember to bring your own. You have the option to reserve linens, at a flat rate of $20 for the entire conference. Would you like to reserve linens from Emory University? No (I’ll be bringing my own.) Yes (Please add $20 to your registration fee.) ATTACHMENTS: Please attach a copy of the following to this form:

1. Health Insurance Card (if applicable) 2. Short Essay Questions 3. Style Your TOMS Party selection(s) (optional)

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CALCULATE YOUR REGISTRATION FEE:

Cost Your Fee

Registration Fee - Early Bird $325

Registration Fee - Regular $400 +

Linens Reservation Fee $20 +

“Style Your TOMS Party” Shoes $44 +

“Style Your TOMS Party” Eyewear Varies +

TOTAL DUE: =

YOUTH INITIATIVE & COLLEGE INITIATIVE PRESS & MEDICAL RELEASE:

1. I authorize any of the leaders of Youth Initiative and/or College Initiative to obtain any and all necessary medical and/or dental attention and/or treatment for me, including surgical procedure if advised by the attending physician. I have listed on this Registration Form any and all special medical problems concerning myself, and I confirm that I have advised the leaders of Youth Initiative and/or College Initiative of any special medical problems.

2. I fully release, discharge, and waive any claim or right of action, which I have or might later have arising from any negligent acts or omission of Youth Initiative and/or College Initiative, any of its employees, agents, or any of the adult leaders arising out of any activity associated with Youth Initiative and/or College Initiative.

3. I agree to indemnify and hold harmless Youth Initiative and/or College Initiative, its employees, agents, and leaders for damages resulting from negligent or intentional acts committed by myself.

4. I authorize publication or broadcast of my image in any press release and/or media publication arising out of any activity associated with Youth Initiative and/or College Initiative.

5. I understand that travel between home and Youth Initiative and/or College Initiative is my responsibility, and I will not hold Youth Initiative and/or College Initiative responsible for accidents or injury related to travel to and from the conference. Furthermore, if I arrive prior to the conference start date and/or leave after the Conference end date, I understand that any and all travel/lodging arrangements are my sole responsibility, and I will not hold Youth Initiative and/or College Initiative responsible for accidents or injury.

6. Private/personal health insurance information must be provided on this Registration From, if applicable. If a participant does not have health insurance, please write “N/A” in the Medical Information Section of this Registration Form and also be advised that, should a participant require medical attention, you and/or your legal guardian (if under 18 years old) are responsible for paying any and all costs not covered by insurance.

YOUTH INITIATIVE & COLLEGE INITIATIVE CODE OF CONDUCT: It is the intent of this covenant to ensure the integrity and dignity of the Youth Initiative Conference, the College Initiative Conference, and all of the participants of both Conferences.

• I understand that I must submit my Registration Form in its entirety and mail it along with the Registration Fee postmarked no later than May 10, 2014, in order to pay the early bird Registration Fee of $325.

• If I miss the early bird registration window, I understand that I must submit my Registration Form in its entirety and mail it along with the Registration Fee postmarked no later than May 31, 2014, in order to pay the $400 Registration Fee.

• I understand that the Registration Form and Fees must be postmarked by May 31, 2014, in order to finalize the registration process.

• I understand that this is a Christian Conference and not a vacation. • I desire to become a leader for Christ and to serve Him. • I will treat all participants respectfully in accordance with the teachings. • I will participate fully in all conference activities with a positive attitude. • I will adhere to the rules and regulations established by Youth Initiative and College Initiative, some of which

are listed here: o Video games, cell phones, tablets, laptops, MP3 players, and the like, or other valuable items are not

permitted during the conference. o Alcohol, illegal drugs, and tobacco are not permitted, even if you are of legal age. o No one may enter the dorm/room/floor of the opposite sex.

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o Everyone must dress appropriately – no skimpy tops, short shorts/skirts, pants/shorts that fall below the hips, etc.

• Upon check-in, I must hand over ALL my electronics including, but not limited to cell phones, iPads and tablets, iPods and other music devices, laptops, etc. (Please see the Electronics Agreement below.)

• Failure to adhere to the code of conduct and/or rules and regulations will result in immediate dismissal from the conference and you will be sent home on the first available flight at you and/or your parent/guardian’s expense.

YOUTH INITIATIVE & COLLEGE INITIATIVE ELECTRONICS AGREEMENT: It is the intent of this covenant to ensure the integrity and dignity of the Youth Initiative Conference, the College Initiative Conference, and all of the participants of both Conferences. I understand that I must hand over ALL my electronics, including but not limited to cell phones, iPads and tablets, iPods and other music devices, laptops, and the like during the check-in process. Prior to arriving at the Conference, I confirm that I have given my parents, legal guardian, and/or emergency contact person the following phone numbers, so that they can reach me in the event of an emergency:

• My Church Pastor and/or Chaperone that brought me to the Conference • YI Program Director – Gloria Kim, 678-925-3415 • CI Program Director – Daniel Cho, 646-808-6336

YOUTH INITIATIVE & COLLEGE INITIATIVE TRACK PRE-REGISTRATION: I understand that I must pre-register and pre-pay for the Tom’s shoes and/or sunglasses in order to participate in the Style Your Toms Party. If I pre-pay for the shoes and/or sunglasses but end up not coming to the conference, I understand that there will not be any refunds and agree to pay a $10 shipping fee to have the item(s) mailed to me. (Items will be shipped within 30 days of receiving the $10 shipping fee.) If no shipping fee is paid or the conference has not heard back from you regarding what you want us to do with your shoes and/or sunglasses within 60 days of the conference end date, your shoes and/or sunglasses will be considered a donation to the conference. LIABILITY RELEASE, WAIVER, DISHCHARGE AND COVENANT NOT TO SUE: * THIS IS A RELEASE OF LEGAL RIGHTS. PLEASE READ BEFORE SIGNING.*

This is a legally binding Release executed by (Participant) ____________________________________ whose address is , and by (Legal Guardian) , whose address is to Korean American United Methodist Youth Initiative, College Initiative, and Emory University (the Institution).

We, the undersigned, request that (Participant) be granted permission to participate in Korean American United Methodist Youth Initiative and/or College Initiative (“Activity”), to be held at Emory University (Youth Initiative and College Initiative are not a function of Emory University) on June 24-28, 2014.

In consideration of the Participant being permitted to participate in the Activity, we do release, waive, forever discharge, and covenant not to sue the Institution, its governing board, officers, agents, employees, and any students acting as employees (“Releasees”), from and against any and all liability for any harm, injury, damage, claims, demands, actions, causes of action, costs, and expenses of any nature which Participant may have or which may hereafter accrue to Participant, arising out of or related to any loss, damage, or injury, including but not limited to suffering and death, that may be sustained by Participant or by any property belonging to me, whether caused by the negligence or carelessness of the Releasees, or otherwise, while Participant is in, on, upon, or in transit to or from the premises where the Activity, or any adjunct to the Activity, occurs or is being conducted.

We have signed this “Release, Waiver, Discharge and Covenant Not to Sue” in full recognition and appreciation of the dangers, hazards, and risks of such activities, which dangers include but are not limited to physical injuries, and which could include serious or even mortal injuries and property damage. We understand that Participant may be transported in private vehicles and engage in athletic activities. We further attest that we have fully discussed the aforementioned risks and hazards, and Participant and Participant’s Parent/Guardian agree that the Participant has individually assumed the risks involved with this Activity as witnessed below.

We understand and agree that Releasees do not have medical personnel available at the location of the Activity or on the campus. We understand and agree that Releasees are granted permission to authorize emergency medical treatment, if necessary, and that such action by Releasees shall be subject to the terms of this Agreement. We state that Participant has no allergies or medical conditions that should be shared with emergency medical providers or we state that the following allergies or medical conditions should be shared with any emergency medical provider in the event Releasees must authorize emergency medical treatment: (list any and all allergies and/or medical conditions) . We understand and agree that Releases assume no responsibility for any injury or damage that might arise out of or in connection with such authorized emergency medical treatment.

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It is our express intent that this release and hold harmless agreement shall bind the members of Participant’s family and spouse, if Participant is alive, and Participant’s family, estate, heirs, administrators, personal representatives, or assigns, if Participant is deceased, and shall be deemed as a “Release, Waiver, Discharge and Covenant Not to Sue” the Above-Named Releasees. Participant’s Parent/Guardian further agrees to save and hold harmless, indemnify, and defend Releasees from any claim by Participant or Participant’s family, arising out of Participant’s participation in the Activity.

In signing this Release, Participant and Participant’s Parent/Guardian acknowledge and represent that we have fully informed ourselves of the content of this Release of liability and hold harmless agreement by reading it before we sign it, and that we have reviewed it and Participant understands what it means and that we sign this document as our free act and deed. No oral representations, statements, or inducements, apart from the foregoing written statement, have been made. We further state that there are no health-related reasons or problems which preclude or restrict the Participant’s participation in this Activity, and that Participant has adequate health insurance necessary to provide for and pay any medical costs that may be attendant as a result off injury to the Participant.

We further agree that this Release shall be construed in accordance with the laws of the State of Georgia. If any term or provision of this Release shall be held illegal, unenforceable, or in conflict with any law governing this Release the validity of the remaining portions shall not be affected thereby.

I, Participant’s Parent/Guardian further state that I am fully competent to sign this Agreement, and that I execute this release for full, adequate, and complete consideration fully intending for myself, for the Participant, and for Participant’s family, estate, heirs, administrators, personal representatives, or assigns to be bound by the same.

AGREEMENT:

By my signature below I acknowledge that I have read and agree to the Youth Initiative and/or College Initiative Press and Medical Release, and Liability Release terms on this Registration Form. I have also read and agree to abide by the Youth Initiative and/or College Initiative Code of Conduct, Electronics Agreement, and Track Pre-Registration. I affirm that all of the information on this Youth Initiative and/or College Initiative Registration Form is true and correct. I also hereby authorize the release of any medical information that might be needed in connection with payments for medical services. I request that payment under my medical insurance program be made directly to the provider on any bills for services rendered by that provider. I understand that I am financially responsible for fees not covered by this authorization. PARTICIPANT’S SIGNATURE DATE PARENT/GUARDIAN’S SIGNATURE (IF UNDER 18 YEARS OLD) DATE YOUTH/COLLEGE/EM PASTOR’S SIGNATURE DATE