Sumter EMC Youth Leadership Experience 2026-27 Parent Permission & Consent for Medical Treatment, Liability, and Public Release

A Leadership Experience

The Sumter EMC Youth Leadership Program will give your student the opportunity to develop skills in leadership and networking. In addition to these skills, this program will offer a variety of experiences. These will include leadership activities and trips where students learn rural electrification history and the operation of electric co-ops, both at the local and state levels. This experience will be all-expense paid by Sumter EMC. In addition, each student will be given a $25 Gift Card per session and a polo shirt and/or t-shirt to wear when representing Sumter EMC. The session in February will require each student to dress in business attire.

To apply, the students must have the following completed by May 1, 2026:

Application
Parent/Guardian Consent Form
Two Teacher or Counselor Recommendations

All of these documents can be found on our website at www.sumteremc.coop/yle.

The qualifications are:

Rising Junior or Senior for the 2026-27 Academic Year
Attend School within Sumter EMCs Service Territory*
Good Standing within the School System
GPA 2.5 or higher

*Home-schooled students qualify, but must reside in a home served by Sumter EMC.

Question Title

* Parent/Guardian Name

First Name

Last Name

Question Title

* Parent/Guardian Contact

Cell Phone

Work Phone

Employer

Question Title

* Emergency Contact

Full Name

Cell Phone

Question Title

* Student Name

Preferred Name

First Name

Middle Name

Last Name

Question Title

* Student Address

Street Address

City

State

ZIP Code

Question Title

* Student Gender

Question Title

* Student Date of Birth

Birthday

Date

Question Title

* School Name

Question Title

* Student Grade (2026-27 Academic Year)

Question Title

* Name four characteristics that best describe your student.

Question Title

* Attendance Commitment and Policy - Please check each box indicating that you agree with each policy.

ATTENDANCE IS REQUIRED AT ALL SESSIONS. Session dates will be provided at the interview.

If an emergency arises, a written request must be submitted to the Youth Leadership Experience Advisor for consideration as to whether the absence is excused.

Students may miss only one full day session and successfully graduate from our program. Participants missing more than one session may be immediately dismissed from the program.

Students are expected to make this program a priority. All schools will be notified with dates and times of activities, requesting each absence to be excused. It is the students full responsibility to discuss their absence with their teachers PRIOR to the event and make up all missed assignments.

Question Title

* I, parent or guardian of the student applicant listed above, acknowledge that he/she has applied for the Sumter EMC Youth Leadership Experience program for July of 2026 to April of 2027. If chosen, I have reviewed the proposed sessions for the program and am making the commitment for my son/daughter to attend all sessions. I understand that transportation to and from Sumter EMC Headquarters at 1120 Felder Street, Americus, GA 31709 for sessions, will be the responsibility of the parent/guardian of the participant. Sumter EMC will provide transportation from the headquarters to the out-of-town locations. Sumter EMC will pay each participant $25 per session, provide meals during each session, and provide each participant with a polo shirt to wear when representing Sumter EMC.

l give my consent for him/her to participate and understand that this participation involves travel within the state of Georgia.

I authorize and direct Sumter EMC, through their staff and volunteer chaperones, to direct and supervise my/our son/daughter. I further request and authorize Sumter EMC, through their staff and volunteer chaperones, to secure any medical or other emergency services the said staff and volunteer chaperones in their reasonable discretion may deem necessary or desirable for my/our son/daughter during his/her participation in the Sumter EMC Youth Leadership Experience Program.

The undersigned acknowledge(s) that I shall be liable for any and all costs and expenses incurred with such medical or other emergency services and treatments rendered to the aforementioned child pursuant to this authorization and will indemnify and hold harmless Sumter EMC. I hereby release and agree to hold harmless Sumter EMC, their officers, members, staff, and associated organizations together with their heirs, successors, or assigns from any and all action, causes of action, claims, damages, costs, expenses, compensation, personal injury, property loss, or any other loss or injury received or incurred by my/our son/daughter during his/her participation in the Sumter EMC Youth Leadership Program.

I hereby grant permission to Sumter EMC to use photographs, likenesses, and/or videotape images of my/our son/daughter in newspapers, magazines, newsletters, videotapes, radio/television broadcasts, and/or Internet Web sites (along with his/her name) for publicity purposes related to this activity.

ELECTRONIC SIGNATURE ACKNOWLEDGEMENT AND CONSENT FORM
I agree and understand that by signing the Electronic Signature Acknowledgment and Consent Form, that all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement. To complete and accept this form, type your full name in the box below.

Question Title

* Please enter the date you have completed this consent form.

Date of Completion

Date

Question Title

* If your student is chosen as a finalist, can they interview on May 11, 2026? Click 'Yes' if so, or click 'No' if there is a conflict. If there's a conflict, we will work with finalists for a make-up.

Yes, May 11, 2026 will be good for my student.

They will be unavailable on May 11, 2026, so they will need a make-up date.

Thank you for completing this Parent Permission & Consent for Medical Treatment, Liability, and Public Release Form for the 2026-27 Sumter EMC Youth Leadership Program. We will announce the finalists for interview on or before Wednesday, May 6, 2026.

Sumter EMC
PO Box 1048 | 1120 Felder Street | Americus, GA 31709
229.924.8041
www.sumteremc.coop

Jacob Peed
Community Connections Coordinator
jacob.peed@sumteremc.com
229.924.8041 Ext. 2235