Name*

Place of Employment*

Title*

Birthday mm/dd/yyyy*

Phone*

Address*

Street Address*

Email*

Today's Date mm/dd/yyyy*

Emergency Contact Name*

Emergency Phone Number*

Emergency Contact's Relationship To You*

Shirt Size*

Please Describe Any Conditions Checked Above and List Any Medications Taken For The Condition

Media Release

I grant permission to DRIVEN LEADERSHIP INC and its subordinates, to use my name and/or photographs for use in DRIVEN LEADERSHIP INC publications such as recruiting brochures, newsletters, and magazines, and to use my name/and or photographs on display boards, and to use my name and/or photographs in electronic versions of the same publications or on the DRIVEN LEADERSHIP INC web site or other electronic forms or media. I hereby waive any right to inspect or approve the finished photographs or printed or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown, and waive any right to royalties or other compensation arising from or related to the use of the photograph. I hereby agree to release, defend, and hold harmless DRIVEN LEADERSHIP INC and subordinates, including any firm publishing and/or distributing the finished product in whole or in part, whether on paper or via electronic media, from and against any claims, damages or liability arising from or related to the use of the photographs, including but not limited to any misuse, distortion, blurring, alteration, optical illusion or use in composite form, either intentionally or otherwise, that may occur or be produced in taking, processing, reduction or production of the finished product, its publication or distribution. Please check the paragraph below which is applicable to your present situation:

I am 18 years of age or older and I am competent to contract in my own name. I have read this release before signing below, and I fully understand the contents, meaning and impact of this release. I understand that I am free to address any specific questions regarding this release by submitting those questions in writing prior to signing, and I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release.By checking this box I am confirming that all information I have entered is accurate and complete, and I agree to hold DRIVEN LEADERSHIP INC harmless of all relevant personal information not disclosed.By checking this box I agree to comply with the instructions and directions of DRIVEN LEADERSHIP INC’s staff members during the program. Furthermore, I agree to indemnify, defend and hold DRIVEN LEADERSHIP INC and its officers, directors, affiliates, employees, staff, volunteers and faculty harmless from any injury to my safety and well-being, including all losses, damages, costs and expenses, including attorney’s fees, for any such injury to my safety and well being.

Signature*

The Advantage: REGISTRATION