Independence City Participant Registration Form

Use this form to register youth participants for the Independence City experience.

Monday, September 25, 2023
10:00am - 3:00pm
Graduate Cincinnati Hotel
151 Goodman St, Cincinnati, OH 45219

Looking for information for volunteers? Check out www.youthatthecenter.org/indycity

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* 1. Participant First Name

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* 2. Participant Last Name

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* 3. Participant Email

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* 4. Participant Age

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* 5. What school does the participant attend? (Put N/A if participant has graduated or is not attending school)

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* 6. Does the participant have any dietary needs (vegetarian/vegan/gluten free, etc.) or food allergies? Please explain to help us coordinate meals.

Adult Contact Information - If an adult is completing this form to register the participant, please complete information below.

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* 7. Adult Contact First Name

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* 8. Adult Contact Last Name

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* 9. Parent/Guardian/Emergency Contact Email

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* 10. Will you be attending Independence City with the participant?

Yes

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* 11. If you will be attending, are you interested in volunteering with the simulation? (We know some agency staff must remain with their participants throughout the day in order to account for their time, while others have flexibility.)

Yes, I am interested in volunteering (we will follow up with additional details)

No, I plan to stay with the participant

I will be dropping off participants and don't plan on attending.

Media Release
In consideration for the opportunity to participate and appear in photographs, digital images and videotape (“Images”), I hereby grant the Hamilton County Mental Health and Recovery Services Board/JOURNEY to Successful Living System of Care the absolute and irrevocable right and permission with respect to the images taken of me or my minor child in which he/she may be included with others:

To copyright the images in the name of Hamilton County Mental Health and Recovery Services Board/JOURNEY to Successful Living
To use, re-use, publish and re-publish the image in whole or in part, separately or in conjunction with other photographs, in any medium now or in the future and for any purpose whatsoever, including (but not by way of limitation) illustration, promotion, advertising; and
To use my or my child’s name in connection with JOURNEY if the Hamilton County Mental Health and Recovery Services Board so decides.

I hereby waive any right that I may have to inspect or approve the Images, their use, or any printed or audio matter that may be used with them, and release and discharge Hamilton County, its elected officials, agents and employees from all and any claims and demands ensuing from or in connection with the use of the photographs, including publication and display on the Hamilton County Mental Health and Recovery Services Board’ website or the JOURNEY website, to include any and all claims for libel and invasion of privacy.

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* 12. I agree to the media release.

I agree