ADULT CONFERENCE PARTICIPATION FORM

IMPORTANT - You must print a copy to return to your group leader (who must then mail it to WorldStrides).

SADD Chapter Name: 

Last Name:   First Name: 

Male  Female                         Name for Nametag: 

T-Shirt Size:  S  M  L  XL  XXL  Other:  I prefer vegetarian meals

Home Street Address: 

City:  State: Zip: 

Home Phone:  Email Address: 

Employer:  Work Phone: 

Cell Phone: 

I am a (choose one):

SADD Advisor      

Adult Chaperone  SADD State Coordinator  Other:

Emergency Contact 1

Name:  Relationship: 

Home Phone:  Work Phone:  Cell Phone: 

Emergency Contact 2

Name:  Relationship: 

Home Phone:  Work Phone:   Cell Phone: 

Name of Health Insurance Provider: 

Policy/ID/Subscriber Number: 

Group Number (if applicable):  Insurance Provider Phone: 

Primary Care Physician (PCP):      PCP Phone: 

Please list any food allergies/dietary restrictions and any other medical condition you think SADD staff should be aware of.

Your signature below indicates that you have read and approved the following:

I have reviewed the information and wish to attend the SADD National Conference. I give my permission to take part in activities, including recreational and social activities that may include water-park rides, horseback riding, community-service projects, and other activities. I will not hold SADD, Inc. or WorldStrides responsible for accident or illness incurred or damage to or theft of personal property, and I waive any claims against SADD, Inc. or WorldStrides except for claims arising from gross negligence or willful acts by SADD, Inc., WorldStrides, or their agents. I give permission to SADD, Inc. to allow photographs, video and audio recordings, and interviews to be taken of me, and I authorize any such photographs, video and audio recordings, and interviews to be published along with my name and agree that they may be used to illustrate, report, promote, and advertise SADD, Inc. or partner organizations, including publication in print media, television, radio, or Internet Web sites. I understand that SADD, Inc. and WorldStrides reserve the right at any time to terminate participation in the SADD National Conference for any participant when, in the judgment of SADD, Inc. or WorldStrides staff, it is in the best interest of the program or participant to do so. I understand no full or partial refunds of conference fees will be given in this circumstance, and I agree to pay any additional fees required to arrange my immediate transportation home.

Signature: _____________________________________ Date: _________________________

This form must be completed and returned to your group leader, who must mail it to WorldStrides.