Pickett. Putnam. Robertson. Rutherford. Sequatchie. Smith. Stewart. Sumner. Trousdale. Van Buren. Warren. Wayne. White.
TENNESSEE OUTDOORS YOUTH SUMMIT 2018 APPLICATION FORM APPLICANT INFORMATION Youth’s Full Name: Address:
City:
State:
Zip:
County:
Email:
Cell Phone:
Gender: (Circle)
Social Security #:
Male
Female
Date of Birth:
T-shirt Size:
Parent/Guardian with whom you reside:
Special Needs, Food Allergies, Requirements or Medical Conditions:
Emergency Contact Name:
Phone:
Have you attended the Youth Summit before? Yes
No
Relationship: (Circle)
2017
2016
2015
2014
Applicant must currently be enrolled in an accredited or equivalent high school or be an incoming freshman in the fall of 2018. Name of High School: Current Grade (April 2018): (Circle)
8th
Freshman
Sophomore
Junior
Senior
Please attach a current photo of yourself with this application. (A printed selfie will be fine)
SCHOLARSHIP INFORMATION Are you requesting scholarship assistance available through TWRF? Yes No If so, you must pay a minimum of $50 for your Youth Summit fee and reside in one of the following TN counties: Bedford Cannon Cheatham Clay Coffee Davidson
Dekalb Dickson Fentress Franklin Giles Grundy
Hickman Houston Humphreys Jackson Lawrence Lewis
Lincoln Macon Marion Marshall Maury Montgomery
Moore Overton Perry Pickett Putnam Robertson
Rutherford Sequatchie Smith Stewart Sumner Trousdale
Van Buren Warren Wayne White Williamson Wilson Page 1
PARENT INFORMATION The Tennessee Outdoors Youth Summit will be held July 15-20, 2018. The week will be physically strenuous. (A typical day will go from 6 a.m. to 7 p.m.) Students will be frequently required to walk and to make some transfers to off-site activities . Also, be aware that it may be hot and humid in July and most activities will take place outdoors. After being chosen for the summit, your child will receive a letter by e-mail or mail and directed to an internet site where you must fill out and submit a class schedule. Total payment or scholarship agreement must be completed at this time. Schedules will not be accepted until payment is fulfilled. The total cost per child is $350 (includes lodging, meals, beverages, off-site travel, t-shirt, cap, equipment usage, educational materials, and various items). Does not include transportation from your home to the Summit. When you arrive with your child on Sunday afternoon, you will be required to attend a rules and regulations meeting that will outline conduct for the week. Poor conduct may result in your child being dismissed from the program and will result in forfeiture of the registration fee. Full or partial scholarships are available to youth in 42 Middle Tennessee counties through TWRF. These scholarships are needand socioeconomic-based and will require a discussion with TWRF staff. We are happy to provide assistance to your child but we must ensure that the money is provided only to those that truly need it. If you would like to request a full or partial scholarship, please indicate your interest on page 1 and someone will be in touch with you. You will still be required to pay a minimum of $50 for your Youth Summit fee. On Friday, the summit ends and your child will be attending the awards luncheon. This is event is casual and fun for everyone. Parents are encouraged to attend the luncheon but will need to pay for the cost of the meal. Everyone must check their child out after lunch. PHOTO AND VIDEO RELEASE: Because the Summit presents so many classic picture taking opportunities, we may use pictures of your son or daughter in our promotional materials (print or web) and event DVD.
PARENT CONSENT Although the Tennessee Outdoors Youth Summit will take reasonable steps to provide a safe environment, I acknowledge that my child participates at his/her own risk. I acknowledge that the Tennessee Outdoors Youth Summit, or any of it’s affiliates, will not be liable for any injury whatsoever that may be suffered by my child. I agree that the Tennessee Outdoors Youth Summit may authorize, on my behalf, whatever medical treatment my child may require. Child’s Name: Parent’s Name:
Parent’s Phone:
In an emergency, I hereby give permission to the licensed physician selected by the Tennessee Outdoors Youth Summit director to hospitalize and secure proper treatment for my child named above. Guardian: (Circle)
Father
Mother
Signature:
APPLICATION INFORMATION • Return this application as soon as possible, postmarked no later than May 25, 2018. • A deposit of $150 is required with this application (unless seeking scholarship). Money will be returned if not chosen. • Make checks payable to TWRF, and send to: Tennessee Wildlife Resources Foundation 5000 Linbar Dr, Suite 275, Nashville, TN 37211 Attention: TOYS
• If you have any questions, please call Lacey Lane at: (615) 831-9311 ext.114, or (731) 415-0641 E-mail:
[email protected]
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