Please review and complete all the spaces on this form.
INCOMPLETE FORMS WILL NOT BE ACCEPTED AND YOUR CHILD WILL NOT BE ABLE TO ATTEND THIS EVENT.
Event Information: March 19—20, 2019 in Lincoln, NE
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Click here if you live outside Lincoln.
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Sponsors click here for your group application.
Transportation: Please indicate which location will be most convenient for you. Participants or groups having difficulties getting to/from a scheduled stop should contact No Limits to see if other transportation arrangements can be made. Transportation to the event and home from the event is not provided for Lincoln youth.
We’d love to help get everyone to Lincoln, but there are a limited number of beds and seats on buses. Acceptance to attend Kick Butts Day will be based on the effort you show in your responses to the following questions. Please answer them in 30–100 words per question.
I hereby request and consent that my child or ward,
, be permitted to travel to and from and participate in the No Limits Kick Butts Day Youth Rally in Lincoln, Nebraska, March 19-20, 2019.
I understand and agree to the following:
I further grant permission for
to appear in person or in voice, video, or photographic presentation for radio, television, or print media reports and/or media campaign(s) resulting from participation in the No Limits Kick Butts Day Youth Rally and also to complete confidential or anonymous surveys and participate in interviews for evaluation purposes.
As a general rule, anesthesia may not be administered to or operation performed without written permission from parents or guardians. However, on rare occasions, an emergency requiring hospitalization and/or surgery develops. Therefore, in order to prevent a dangerous delay, if an emergency does occur and we are unable to contact a youth’s parents or legal guardian, the parent/guardian is asked to sign the release form below.
In the event of injury or illness to my son/daughter/ward,
I hereby authorize official meeting staff to secure whatever treatment is deemed necessary and, if recommended by an attending physician, the administration of an anesthetic or surgery.
I hereby authorize the event staff member to administer over-the-counter medication if necessary [e.g., Tylenol® (headache, fever), Advil® (cramps, aches), Pepto-Bismol® (upset stomach, nausea), Benadryl® (allergies)].
WHEREAS, the possession and/or use of weapons, tobacco products, alcoholic beverages and illegal drugs, or
remaining in the presence of individuals who are using or taking these items is prohibited; and
WHEREAS, sexual contact at any event or activity which occurs within the time frame of the Kick Butts Day Youth Rally is prohibited; and
WHEREAS, all water activities including, but not limited to, the use of a hot tub, Jacuzzi, or swimming pool facilities, swimming, boating, tubing, etc. at any event or activity within the time frame of the No Limits Kick Butts Day Youth Rally are prohibited; and
WHEREAS, any behavior that violates any of the laws of the United States or the State of Nebraska or any local ordinance is also prohibited; and
WHEREAS, the attendance and punctuality at all scheduled sessions and activities at the event is considered mandatory by all participants at the Kick Butts Day Youth Rally; and
WHEREAS, there is a commitment to serve as a contact and resource person in my community/county/state tobacco education program; and
WHEREAS, all groups and individuals are expected to remain at No Limits Kick Butts Day Youth Rally for the entire duration of each day’s activities, which is being held primarily at the First Christian Church. Students will also be walking to various downtown Lincoln locations for activism purposes and must remain at these locations with their sponsors.
**** IMPORTANT NOTICE ****
This will not affect the selection process; it’s simply to allow accommodation for all special needs.
Special Needs: Please indicate any special needs (allergies, medical conditions, medications, etc.) or disabilities that we should know about. Include any relevant information in this form. We will contact you for further information, if needed.
Special Dietary Needs: Please indicate any special dietary needs such as vegetarian or kosher restrictions or food allergies.
Please Note: All water activities are strictly prohibited for participants for the duration of the
No Limits event due to liability issues. Water activities include, but are not limited to, the use of any swimming or hot tub facilities at the hotel.
Please submit all consent forms to Molly Kincaid by Wednesday, February 13, 2019.Acceptance announcements will be made no later than Wednesday, February 20, 2019.