Empower Teen Leaders Application

We (the applicant, parent(s), and school official) certify that all information contained in this application is true and factual.  We also agree that if applicant is selected for the PACC Empower Teen Leaders the applicant’s name, photos, and likeness and any other information or materials provided by applicant to this program may be used for purposes of news, publicity, PACC website, and advertising in all media.  The application may be released to applicant’s school office.

If accepted into this program, there is a commitment to full participation.  Sessions will be held for a two-week session from 9-3PM and will be held at PACC offices, unless otherwise notified.  Dress code will consist of business casual or casual dress of nice jeans (no holes).     

The cost of the program is $50, payable after selection.  

Applicant's Name:*
Address:
Applicant's E-mail:*
Appllicant's Cell Phone:
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Parent/Guardian's Name:
Home Phone:
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Parent/Guardian's Work Phone:
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PACC EMPOWER TEEN LEADERS

GENERAL EXCURSION PERMISSION

LIABLILTY WAIVER/MEDICAL RELEASE

During the PACC Empower Teen Leaders, there may be times when your child will be transported to different locations for PACC Empower Teen Leaders sessions.  We request your signed permission to do so during this program.  We will make every effort to notify you in advance as to where and when these activities will take place.  If you do not wish your child to go on a specific activity, you may contact the PACC at that time.  Parents, by signing below you are granting permission for your child to participate in the PACC Empower Teen Leaders and you are releasing the PACC, Piqua City Schools, Lehman Catholic High School, Upper Valley CC, cooperating businesses or services, and all volunteers of any liability associated with your child’s participation in this program.   

Date:
Parent Guardian Electronic Signature:*