2015 YOUTH SUMMIT: TOGETHER WE CAN

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1 2015 YOUTH SUMMIT: TOGETHER WE CAN What is Project UNIFY? Project UNIFY is a sports and education program that partners students with and without intellectual disabilities to create a more inclusive school environment where students are able to work together, excel athletically and academically regardless of ability. ABOUT THE 2015 YOUTH SUMMIT Nearly 100 student leaders from across the State of Florida will participate in a two-day Summit that will share how sports can be a platform for a social justice movement and an opportunity to advance an effective campaign for change in their schools and communities. The youth-led Summit will also provide a forum for youth to enhance the knowledge and skills necessary to engage and activate others in a movement of respect and inclusion. IMPORTANT INFORMATION: Date: June 26 th 27 th Location: University of South Florida Theme: Together We Can Participating Students: Athletes (students with intellectual disabilities) and Partners (students without intellectual disabilities) Eligibility Criteria: Graduating Eighth graders/9 th 12 th graders/incoming College Freshmen Please submit Youth Athlete/Youth Partner + Adult Staff Mentor forms together First Come, First Serve 1 st 100 students that submits 2015 Youth Summit Participation Form will be selected to attend the Youth Summit Athlete/Partner does not have to attend a current Project UNIFY School (However priority will be given to current Project UNIFY school members) Fostering respect, dignity and advocacy for people with intellectual disabilities.

2 2015 Youth Summit Participation Form This form is to be completed by any partner, athlete and/or mentor attending the 2015 Special Olympics Florida Project UNIFY Youth Summit. Please return to Darrell Taylor at by April 24, Special Olympics Florida County Program: Full Name: Preferred Name (nickname): Participant Registration Information (First) (Middle) (Last) Gender: Male Female Date of Birth: Current Age: Mailing Address City: State: Zip Code: Address: Home Number: ( ) Cell Number: ( ) Role at P.U. Summit: Youth SO Athlete Youth Partner Adult Staff Mentor T-shirt Size (adult sizes) Preferred Roommate: Grade Level: Small Medium Large X-Large XX-Large Other: School Name: How many years have you been involved with Special Olympics Florida? With your commitment, please submit a 2 x 2 passport-style photo for your Project UNIFY Youth Summit credential. Photos should be sent as jpegs to Darrell Taylor at darrelltaylor@sofl.org. Credential photo sent to Darrell Taylor

3 Emergency Contact Information Emergency Contact Name: Relationship: Day Phone: ( ) Day Phone: ( ) Cell Phone ( ) Emergency Contact # 2 Name: Relationship: Day Phone: ( ) Day Phone: ( ) Cell Phone ( ) Do you have any food restrictions? Please list any specific food allergies or restrictions: Food Restrictions and Accessibility Requirements Yes No Are you a vegetarian? Yes No Do you have any specific accessibility requirements? (i.e. wheelchair accessible) Medicines: Insects/Bites: Other: Additional Allergy Information (Please list all relevant allergies)

4 Health History: To Be Completed by Parent/Guardian Yes No Yes No *Heart Disease, Heart Defect or High Blood Pressure Contact lenses or glasses *Chest Pain Hearing loss or hearing aid *Seizure, Epilepsy or fainting spells *Asthma *Diabetes Easy bleeding *Concussion or serious head injury Emotional, Psychiatric, Behavioral *Major surgery or serious illness Sickle cell trait or disease Heat stroke or exhaustion Bone or joint problems *Blindness or visual problems Immunizations up-to-date Other (please list): {*} Requires note from doctor before travel Medication Information Medication Name Dosage Date Prescribed Times per Day Health Insurance Provider: Policy Number: Policy Holder Name: Health Insurance Information Policy Holder Signature: Printed Name: Date:

5 Code of Conduct for Youth and Mentors To ensure all participants have a safe and fun experience, all participants (youth and mentors) need to agree to the Code of Conduct. Please initial next to each code and sign at the bottom. I will dress and act in a responsible manner that will be a credit to Special Olympics Florida and my school. I will respect all residential sites, meeting sites, dining facilities, and other activity areas. I will treat all participants with respect and communicate in a courteous manner. I will follow all directions from State Mentors, Youth Summit staff and Project UNIFY staff. I will arrive on time and be prepared for all sessions, scheduled events, meals and any other activities. I will NOT engage in any inappropriate contact or relationship with Special Olympics Florida athletes, partners, mentors, staff or volunteers. I will NOT drink alcohol, smoke or take illegal drugs while at the Youth Summit. I will obey all laws and Special Olympics Florida rules. I will provide for the general welfare, health and safety for all Special Olympics Florida athletes, partners and mentors. Participant Signature (all participants) Parent/Guardian Signature (for youth) I commit to attend the 2015 Youth Summit and agree to follow the Code of Conduct. I am the parent/guardian of the participant named above. I permit the participant to attend the 2015 Youth Summit and have explained the need for the participant to follow the Code of Conduct.

6 Name of Participant: School Name: Youth Participant Release Form 1. I am the parent/guardian of the participant named above (the participant). I hereby represent that the participant has my permission to participate in the Project UNIFY activities at the 2015 Special Olympics Florida - Project UNIFY Youth Summit in Tampa, FL. I further represent and warrant that the participant is physically and mentally able to participate in such activities. 2. I am specifically granting my permission on the participant s behalf to Special Olympics Florida (SOFL) to use the participant s likeness, name, voice and words in television, radio, film, newspapers, magazines, on the Internet and in all other media, and in any form, for the purpose of advertising or communicating the mission and activities of Special Olympics Florida and/or applying for funds to support Special Olympics Florida. 3. I hereby irrevocably and exclusively assign to SOFL all copyright and other right, title and interest (including moral rights) in and to the participant s work product related to the 2015 Youth Summit, including all photographs he or she may take, videos he or she may make and articles/blogs/tweets/posts he or she may write, in perpetuity, to use in all media, without further obligation to the participant. 4. If a medical emergency should arise during the participants participation in any Special Olympics Florida activities, at a time when I am not personally present so as to be consulted regarding the participant s care, I hereby authorize SOFL and/or the 2015 Youth Summit staff, to take whatever measures are necessary to ensure that the participant is provided with emergency medical treatment, including hospitalization.

7 5. I fully understand that the activities of the 2015 Youth Summit may involve risks of serious bodily injury, including permanent disability, paralysis and death, which may be caused by the participant s own actions, or inactions, those of others participating in the event, the conditions in which the event takes place, or the negligence of the "Releasees" named below; and that there may be other risks either not known to me or not readily foreseeable at this time; and I fully accept and assume all such risks and all responsibility for losses, costs, and damages I and/or the above named minor incur as a result of my and/or the participant s participation in the event. I hereby release, discharge, and covenant not to sue SOFL and/or its directors, agents, officers, volunteers, and employees, other participants, any sponsors, advertisers, and, if applicable, owners and lessors of premises on which the event takes place, (each considered one of the "Releasees herein) from all liability, claims, demands, losses, or damages on my account caused or alleged to be caused in whole or in part by the negligence of the Releasees or otherwise, including negligent rescue operations; and I further agree that if, despite this release, waiver of liability, and assumption of risk I, or anyone on the participant s behalf, makes a claim against any of the Releasees, I will indemnify, save, and hold harmless each of the Releasees from any loss, liability, damage, or cost which any may incur as the result of such claim. 6. I am the parent or guardian of the participant and have the legal authority to enter into this Youth Participant Release Form on participant s behalf. I have read this YOUTH PARTICIPANT RELEASE FORM, and have explained these provisions to the participant. I understand that on behalf the participant, I have given up substantial rights by signing this document and have signed freely and without any inducement or assurance of any nature and intend it be a complete and unconditional release of all liability to the greatest extent allowed by law and agree that if any portion of this agreement is held to be invalid the balance, notwithstanding, shall continue in full force and effect. Signature: Date: Printed name of Parent/Guardian:

8 Name of Adult Mentor: School Name: Adult Staff Mentor Release Form 1. I, the above-named participant, am at least 21 years old. I represent and warrant that, to the best of my knowledge and belief, I am physically and mentally able to participate in the Project UNIFY youth activities as a mentor at the 2015 Special Olympics Florida Project UNIFY Youth Summit. I understand and agree that as a mentor, I will be responsible for, among other things, supervision and traveling with youth participants. 2. Special Olympics Florida (SOFL) has my permission, (both during the 2015 Youth Summit and anytime thereafter) to use my likeness, name, voice, or words in either television, radio, film, newspapers, magazines, on the Internet and other media, and in any form, for the purpose of advertising or communicating the mission and activities of Special Olympics Florida and/or applying for funds to support the mission and activities. 3. I hereby irrevocably and exclusively assign to SOFL all copyright and other right, title and interest in and to my work product related to the 2015 Youth Summit, including all photographs I may have taken or videos I have filmed and/or articles/blogs/tweets/posts I have written, in perpetuity without further obligation to me. 4. If, during my participation in Special Olympics Florida activities, I should need emergency medical treatment, and I am not able to give my consent or make my own arrangements for that treatment because of my injuries, I authorize Special Olympics Florida to take whatever measures are necessary to protect my health and wellbeing, including, if necessary, hospitalization.

9 5. I fully understand that the activities of the 2015 Youth Summit may involve risks of serious bodily injury, including permanent disability, paralysis and death, which may be caused by my own actions, or inactions, those of others participating in the event, the conditions in which the event takes place, or the negligence of the "Releasees" named below; and that there may be other risks either not known to me or not readily foreseeable at this time; and I fully accept and assume all such risks and all responsibility for losses, costs, and damages I incur as a result of my participation in the event. I hereby release, discharge, and covenant not to sue SOFL and/or its directors, agents, officers, volunteers, and employees, other participants, any sponsors, advertisers, and, if applicable, owners and lessors of premises on which the event takes place (each considered one of the "Releasees herein) from all liability, claims, demands, losses, or damages on my account caused or alleged to be caused in whole or in part by the negligence of the Releasees or otherwise, including negligent rescue operations; and I further agree that if, despite this release, waiver of liability, and assumption of risk I, or anyone on my behalf, makes a claim against any of the Releasees, I will indemnify, save, and hold harmless each of the Releasees from any loss, liability, damage, or cost which any may incur as the result of such claim. 6. I have read this Adult Staff Mentor Release Form, and understand that I have given up substantial rights by signing it and have signed it freely and without any inducement or assurance of any nature and intend it be a complete and unconditional release of all liability to the greatest extent allowed by law and agree that if any portion of this agreement is held to be invalid the balance, notwithstanding, shall continue in full force and effect. Signature of Adult Mentor: Print Name: Date: