Register for the Mental Health Bootcamp

STUDENT INFORMATION

First name

Last name

Address

City

State

Zip Code

Phone

Alternate Phone Number

Birthday

Gender

Current School

Current School Address

Current School City

Current School Zip Code

PARENT/ GUARDIAN INFORMATION

First name

Address

City

State

Zip Code

Phone

Alternate Phone Number

MEDIA RELEASE FORM

I hearby grant Greater Milwaukee Urban League permission to use my digital image, along with my first name, reference to my alma mater, and additional relevant information in any and all ofits advertisements, publications, promotional materials and online platforms, without payment or any other consideration.

I understand and agree that these images will become the property of Greater Milwaukee Urban League and will not be returned.

I hearby irrevocably authorize Greater Milwaukee Urban League to edit, alter, copy, exhibit, publish, or distribute these images for purposes of publicizing Greater Milwaukee Urban League's programs or for any other lawful purpose related to the work of the Milwaukee Urban League. In addition, I waive the right toinspect or approve the finished products, including written or electronic copy, wherein my image appears.

Additionally, I waive any right to royalties or other compensation arising or related to the

use of the digital images.

I hereby hold harmless and release and forever discharge Greater Milwaukee Urban League from all claims, demands, and causes of action which I, my heirs, representatives, executor, administrators, or any other person acting on my behalf or on behalf of my estate may have or may have by reason of this authorization.

Parent/ Guardian First Name

Parent/ Guardian Last Name

Parent/ Guardian Signature

Today's Date

Do you have any information about your child's mental health? If so, what mental health conditions do they have?

Thanks for registering to our event. See you there!