2022 Middle School Overnight Summer Leadership Conference Registration

Page 1 of 8

WAIT LIST ONLY: We have sold out our LMU OVERNIGHT Program for Summer 2022. Our DAYS ONLY Program has availability. Please go to www.tacsc.org/programs to find the registration link for the DAYS ONLY program

Register for our 2022 Middle School Overnight Summer Leadership Conference!

For this registration type, students will stay overnight on the campus of Loyola Marymount University for the duration of the Conference.

Regular Registration Fee for Four Days / Three Nights is $899. This includes room, meals and all supplies.

Late Registration Fee: Anyone registering less than two weeks prior to a conference will incur a $100 late registration fee ($999 total).

A $100 non-refundable deposit is required to reserve your spot for Summer Conference. All deposits are fully refundable if any cancellation or postponement actions are necessary due to COVID-19.

TACSC will follow all recommended COVID-19 safety precautions at the time of the event. Stay tuned for more information as we get closer to the event dates. All transportation will be the responsibility of the students to arrive and depart safely to and from campus.

NOTE: After you submit this registration form, you will be emailed with a confirmation of this registration and a unique Registration Number (SLC#####). Please keep this registration number for future reference.

Select the Conference Date

Please select the date below:

WAIT LIST ONLY: Overnight Program at Loyola Marymount University | Thursday, June 23 – Sunday, June 26, 2022

Please provide information for the parent submitting this Registration form

Registration Type

Registration Type and Fee are updated automatically for Early Bird, Regular and Late registration cycles.

Registration Type

Registration Fee

$

Click Next Page to register your student.

Page 2 of 8

Delegate Registration

Please select the State of your student's School, and then the School.

If your student's School is NOT listed, check on the box below to enter the school's information.

Note: Schools are listed in alphabetical order, with their Cities.

Find Student's School

State of School

Select the School

ONLY check this box if

School is not listed

Enter all information for the School

Full Name of School

School City

School State

Delegate First Name

Delegate Last Name

Delegate Email Address

Do NOT enter the same email address as the parent(s). Please enter a separate email for the student or leave blank.

Delegate Cell Phone

(To be used during conference only)

Street Address

City

State

ZIP Code

Grade in September 2021

Year graduating from Junior High School

Year graduating from High School

Gender

T-Shirt Size (adult sizes)

Please list any extracurricular activities in which the delegate is involved

(leadership, sports, youth group, honor club)

Has this student ever attended a TACSC Student Leadership Summer Conference before?

No

Yes

Page 3 of 8

Send conference details to

Contact information was provided on Page 1 of this form for:

Depending on your selections, contact information boxes will appear below.

Contact Information for Mother or Father if needed

Mother's Contact Information

First Name

Last Name

Cell No.

(for emergency contact during conference)

Email Address

Mother Address

Street Address

City

State

ZIP Code

Father's Contact Information

First Name

Last Name

Cell No.

(for emergency contact during conference)

Email Address

Father Address

Street Address

City

State

ZIP Code

Page 4 of 8

Please provide the student's medical information.

Medical Form Information

Are there any existing medical conditions or food allergies TACSC should be aware of?

Write "N/A" if none

Are there any medications the student will bring with them to conference?

If so, please list medication, frequency, and dosage. Write "N/A" if none

Doctor & Insurance Information

Primary Doctor Name

Primary Doctor Phone No.

Please provide insurance carrier

Please provide insurance policy number

Please provide two contacts for the student in the case of an emergency during the conference.

Contact Information Available For...

Contact information was provided on Page 1 of this form for:

Check this box if this person is an emergency contact

The Page 1 contact is an emergency contact

Contact information was provided on Page 3 of this form for:

Check this box if this/these person(s) is/are an emergency contact(s)

The Page 3 contact(s) is/are an emergency contact(s)

Additional Emergency Contacts

Enter up to two (2) additional Emergency Contacts

Contact #1 First Name

Contact #1 Last Name

Contact #1 Phone No.

Contact #2 First Name

Contact #2 Last Name

Contact #2 Phone No.

Page 5 of 8

Please provide any scholarship information for the student. If there are multiple scholarships, please enter all names where requested and the sum of all scholarships as the amount.

Scholarships

Are you receiving any scholarships or official funding to attend?

YesNo

What is the name of the scholarship organization?

What is the amount of the scholarship?

$

Please enter a value greater than or equal to 0.

Is your student eligible and participating in the Federally approved National School Lunch Program?

YesNo

Page 6 of 8

Subtotal

Registration Type:

Seminar Registration Fee:

$

Scholarship (if provided):

$

Subtotal

$

Help support TACSC

Can you help support TACSC and its mission to spread leadership to young students through scholarships and additional funding?

Enter a donation amount (optional)

$

Page 7 of 8

Order Total

Registration Type:

Seminar Registration Fee:

$

Additional Donation:

$

Subtotal:

$

Minus Scholarship (if provided):

$

TOTAL

$

GRAND TOTAL AMOUNT:

$

You will need to pay at least $100 towards the cost of the registration.

How much will you pay today towards the registration?

$

Total Charges Due Today (PayPal total):

$

The total amount to be paid later is calculated as follows: TOTAL minus Total Charges Due Today

Amount to be paid later

$

A $100 non-refundable deposit is required at the time of conference registration. Cancellations made 30 days or more prior to the first day of the conference will result in a refund of all monies paid except the referenced $100 deposit. Cancellations made between 14 and 30 days prior to the first day of the conference will result in a refund of 50% of all monies paid. Cancellations made less than 14 days prior to the first day of the conference will result in the full forfeiture of monies paid; no refund will be available. We thank you for your understanding and co-operation.

By clicking submit, you are giving TACSC permission to supervise the safety and education of your child for the duration of the TACSC Program. This is your "permission slip" many of you are familiar with from your schools.

By clicking submit, you are giving TACSC permission to take photos and video during the conference to promote TACSC programs and activities. TACSC will never post any photos or videos with name or location information. If you see a photo or video of your child that you wish removed, please contact us immediately.

By clicking submit, you authorize TACSC to provide appropriate emergency medical care based on the medical information provided on this registration form. TACSC will contact the primary contact and all emergency contacts that were provided on this form as needed.

After you click SUBMIT, you will be taken to PayPal to submit payment for this registration.

Your registration is not complete until you have submitted payment.

You will receive a confirmation email with details of this registration and a unique Registration Number (SLC#####). Please keep this registration number for future reference.

Paypal_Hidden_Fields

Life Leadership Lessons	President	VP
Secretary	Treasurer	Religious Coordinator
Spirit	Historian	Safety/Ecology
Class Representative	Publicity