Healthy Young Nevadan Summit Registration

The Youth Summit aims to support mental health, substance misuse prevention education, public health models, and youth leadership.

Deadline to register: July 12th, 2024 end of day
Date: July 26th, 2024
Registration: 8:00am - 9:00am
Summit: 9:00am - 3:00pm
Location: University of Nevada, Reno

1. Name *This question is required.

2. Age (on the day of the Summit, July 26th, 2024) *This question is required.

3. Gender *This question is required.

Please enter an 'other' value for this selection.

4. Ethnicity

5. Address (Street address, State, County, Zip Code) *This question is required.

6. Student Phone Number *This question is required.

7. Student E-mail Address *This question is required.

8. T-shirt Size *This question is required.

S
M
L
XL
Other - Write In (Required) Please enter an 'other' value for this selection. * This question is required.

9. Are you a Silver Summit Health Plan Member? *This question is required.

10.

Student Agreement:

As a participant of the Healthy Young Nevadan Summit, I agree to have fun, give my best, do what I can do to enhance the summit for
myself and for all the other participants, and abide by the following Code of Conduct:

I agree to abide by the rules and regulations for the Healthy Young Nevadan Summit.

I agree to respect the property and others.

I agree that I will participate and attend all activities on time.

I understand that there will be no tobacco use, in any form during the summit.

I understand that cell phones and other electronics are not allowed during learning workshops, unless stated by facilitator or an emergency arises, and any violation will result in the item being held by staff.

I understand that illegal substances of any kind (including alcohol, nicotine/vapes, and marijuana) are not tolerated at the summit because they are destructive to the group and individual. Any participant under the influence or in possession of alcohol and/or other drugs will be immediately removed from the summit.

If your agreement to the Code of Conduct is faulted, you will be dealt with in accordance with the following consequences:

While hearsay alone cannot lead to immediate suspension, it will lead to an investigation.

Upon the determination that a violation has been committed, the participant will be sent home immediately at his/her expense.

In the event that a participant is knowingly found to be or admits to having been in the presence of a participant in violation of the above stated policy, disciplinary action will be taken at the discretion of the summit staff.

I have read and understand the Summit Code of Conduct and consequences of the Healthy Young Nevadan Summit. I will adhere to them and realize that a violation of these rules may result in my being sent home early (at my own expense). I also agree to commit to the activities expected of me, as stated above. *This question is required.

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Signature of

11.

Parental Consent:

The following page MUST be filled out and signed by a parent or guardian if participant is under the age of 18. If 18, please sign as self.

I give my permission for my child/myself, to attend the Healthy Young Nevadan Summit in person at the University of Nevada Reno.
I hereby release all employees and associates of the Healthy Young Nevadan Summit from any liability resulting from events beyond its control. All employees and associates of the Healthy Young Nevadan Summit will make every effort to contact parents/guardians immediately if necessary.
I have read and agree to support the regulations outlined in the “Student Agreement” section.
I release the Healthy Young Nevadan Summit and affiliate partners to use all photographs and/or video/audio of me/my child taken during summit activities.

*This question is required.

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Signature of

12. Primary Guardian *This question is required.

First Name

Last Name

Email Address

Phone Number

13. Emergency Contact (Other than parent/guardian listed above) *This question is required.

First Name

Last Name

Relationship to Registrant

Emergency Contact Phone Number

14. Student Health Information:
(If selected yes to any of the questions, please provide an explanation) *This question is required.

Student Health Insurance Carrier

Policy Number

Does your child have any Allergies and/or Dietary Restrictions?

Does your child have any medical conditions we should know about?

Is your child currently taking any medications?

Does your child have any physical limitations that we should know about?

Does your child have any mental health conditions we should know about?

15.

Guardian Waiver:
In the event of illness or injury, I do hereby consent to whatever x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care and emergency transportation considered medically necessary in the best judgment of the attending physician, surgeon, nurse or dentist be performed under the supervision of a member of the medical staff of the hospital or facility providing medical or dental services. I hereby agree to waive all claims against Join Together Northern Nevada, it’s employees and its affiliates including but not limited to Silver Summit Health Plan, University of Nevada Reno, Upward Bound and Upward Bound Math Science Programs, NRAP, CASAT, or any agency and individual in which we partner with for a specific event or project. The named above will be held harmless and are not any and all liability of claims that may arise out of/or in connection with my child’s participation in this and any activities. Join Together Northern Nevada, and its partners, provide no medical insurance for such treatment and the cost thereof will be my sole responsibility.

I, the guardian, fully understand that the participants are to abide by all the rules and regulations for any and all events and travel.

*This question is required.

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Signature of