BNV 2019 Registration - Participant Form

Page 1

Festival Summary

Poets, coaches, chaperones, entourage, etc. must complete this form before the festival.
Festival Dates: July 17th - 21st, 2019
Location: Las Vegas, NV
Address: 4505 S. Maryland Pkwy, Las Vegas, NV, 89154

Deadlines: Registration is due May 17th, 2019

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Participant Information

Participant Contact

Participant Address

Participant Details

Parent / Guardian Contact

Roommate Preferences
Preference #1

Preference #2

Preference #3

Team Information

Coach Contact

Chaperone Contact

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Medical Information

Emergency Contacts



Indicate medication(s) that are taken on a regular basis. Note that participant should bring an adequate supply of all medication(s) with them.
Medication Information

Prescribing Physician

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Health Insurance

Please complete this form in its entirety. Private insurance information must be provided,if applicable. If a participant does not have private health insurance, please be advised that, should a participant require medical attention, the sponsoring organization/team is responsible for paying any costs not covered by insurance.
Insurance Information

Insurance Company Address

Policy Holder Information

Policy Holder Address

Physician Information

Physician Address

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Agreement & Permission

By signing below, I (and my guardian/parent if I am under 18) acknowledge that I will travel to Las Vegas, NV, with the organization named above, a nonprofit organization/school/etc based in city named above, on Wednesday, July 17, 2019 and will return on Sunday, July 21, 2019. Once in the Houston area, all local travel will be taken care of by Youth Speaks. If there are updates in this status, you will be notified with two weeks notice prior to the trip. 

ORG/ADULT REP assumes all responsibility during the dates of the festival for my/my child’s safety, travel, food, and lodging throughout the duration of the trip within reason and within their control, but does not assume responsibility for my/my child’s individual behavior. I acknowledge also that at no time during the weekend will I/my child engage in any acts that are illegal, which may include such acts as engaging in the drinking of alcohol or taking of drugs. If I/my child do engage in such behavior, I/my child will be sent home immediately. 

I understand also that I/my child will be supervised at all times by adult organizers of the event and by my Mentors/Chaperones as assigned by ORG/ADULT REP. I/my child will also participate in all aspects of the festival, including workshops, performances, and group activities. I will not leave the residence after hours without the specific permission and accompaniment by my mentor chaperones.
Medical Consent
By signing below, I am giving my permission for myself (or my legal guard or child under the age of 18) to participate during Brave New Voices 2019 in Las Vegas, NV, with these understandings.

I hereby authorize the release of any medical information that might be needed in connection with payment for medical services.

I request that payment under my medical insurance program be made directly to the provider on any bills for services rendered by that provider. I understand that I am financially responsible for fees not covered by this authorization.
BNV Standards of Behavior (Youth & Adults)
The Standards of Behavior form must be signed by all Brave New Voices participants prior to coming. These standards will be applied across the board for all youth under the age of 20. As a youth leader/poet/genius participating in Brave New Voices 2019 in Las Vegas, NV. I agree and understand the following:

1. I am here to celebrate the power of the youth voice, and as such, will do my utmost to represent the positive spirit of the Brave New Voices International Youth Poetry Slam Festival, and will act responsibly throughout my stay.

2. There will be no drinking of alcohol or illegal drug use at anytime. There will be no illegal behavior during the festival of any kind. Failure to comply with this will result in my immediately being excused from the festival. I will discourage others from engaging in this activity as well.

3. There will be no leaving the University campus or any of the locations without direct chaperone supervision by one of the assigned chaperones, over the age of 21. Failure to comply with this will result in my immediately being excused from the festival and in some cases disqualification for your team from participating in the Slam.

4. No guests not affiliated with the festival will be allowed at the dormitory at anytime. Failure to comply with this will result in my immediately being excused from the festival. All Brave New Voices attendees must be at the dormitory no later than 12:30am each night.

5. There will be no violence allowed at anytime. Failure to comply with this will result in my immediately being excused from the festival.

6. As a team member, I am responsible to attend and be present at all assigned activities. I will not abandon my team, nor disappear. I will be available at all times during the festival.

7. I understand that sexual activity is strongly discouraged during the festival. I will get my numbers, and call them later.

8. All attendees will be given a permission slip and an emergency contact card. I will have these signed by my parent/chaperone before attending Brave New Voices.

By Signing below, I agree to these understandings.
BNV Standards of Behavior (Adult Chaperone/Coach/Mentor)
I understand that as an adult participant during Brave New Voices, I take my role as chaperone/mentor seriously. I know that while I will have an incredible time, Brave New Voices is not designed specifically for me. It is for the youth. Toward that end, I will do everything to support their health and well - being during the festival, and agree to the following:

1. My team will participate in all of the planned activities during the entire Brave New Voices Festival. I understand that there were more teams who wished to participate this year than were able, so I and my team will take advantage of the full spectrum. If I/ my team diverge from this, I will notify Brandon Santiago or Tish Jones in advance, and understand that if I don’t, this will be taken into account next year during the registration process.

2. I understand that all youth under the age of 20 who travel as part of my group will require ongoing supervision, and will not be allowed to leave the dormitory or other venues without my or another chaperone’s supervision.

3. I will not allow anyone under the age of 21 to drink any alcohol, participate in illegal drug usage or other illegal behavior, and understand that there is a zero - tolerance rule for such behavior this year. If I catch one of the youth I am responsible for engaging in such behavior, it is my duty to make sure the youth is removed from the festivities.

4. I understand also that I will not drink nor participate in illegal drug usage around the y outh, under the age of 21. If I decide to go out, I will make sure the youth I am responsible for are properly chaperoned by another member of my organization.

5. I will strongly discourage sexual activity among the youth, and will make sure that no illegal activity will occur. In Houston, statutory rape involves anyone over the age of 18 engaged in sexual activity with anyone under the age of 18.

6. I understand that at no time will I smoke, or allow anyone else to smoke, cigarettes in doors. I will do my best to assure that if I smoke, I will do so far away from any youth, and will not share my cigarettes with any youth.

7. Even if I have friends in Houston, I will not invite them to the Dormitory. We will find other places and times to be together.

8. I will make sure that my team has returned to the dorm no later than 12:30am each night.

9. I understand that I am required to be finger printed and cleared by the US Department of Justice before I can attend the Brave New Voices Festival if I am 18 or older. (Clearance must be confirmed by the organization you represent.)

By Signing, I agree to these understandings.
Media Release
Event Name: Brave New Voices 2019 

Event Dates: July 17th - 21st, 2019 

Event Location: Las Vegas, NV

I am a performer/presenter/speaker for the above event. I understand the event will be videotaped and recorded for the purpose of being used and distributed in various formats by the Youth Speaks Inc. for educational, archival, and promotional purposes, including the Internet (including webcasts, podcasts, and youtube), and any other communications medium currently existing or later created. I give my permission and authorize Youth Speaks Inc. to videotape, audiotape, photograph, record, edit or otherwise reproduce my work, and to use it in the formats and for the purposes stated above. This release form does not cover commercial purposes. I authorize Youth Speaks Inc. to share my work with third parties that meet Youth Speaks Inc. programmatic standards.

I agree to indemnify and hold harmless Youth Speaks Inc., their employees and representatives against any and all claims arising out of my presentation, including, but not limited to, claims of copyright infringement, defamation, and misrepresentation. I will not seek compensation for the photos or videos.

I declare I have read the above, fully understand its meaning and effect, and agree to be bound by it. If you are under 18 years of age, you are required to have the permission of your parent/legal guardian.

For performers under 18 years old, your parent’s/legal guardian’s signature is required.
Background Checks
Background check document for all participants, coaches, chaperones over the age of 18 is required.
Please upload one of the following documents:
1. Official Documentation from a State/Federal Agency showing adult chaperones, coaches and attendees have been cleared to work with youth in your organization

2. Letter on Official Letterhead Signed by the Executive Director that states that adult chaperones, coaches and attendees from your team have been cleared by a federal/state agency to work with youth in your organization. Please use full names of the adults in this letter.

Signatures must be preceded by /s/ to be valid.