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MOVE Conference

Name of School*
Young Man's Name*
First Last
Young Man's Age*
Young Man's Grade Level*
Parent/Guardian
First Last
Parent/Guardian Email
Relationship to Student
Phone*
Email*
Please include any special dietary needs for the young man (if any)
Please include any medical needs for the young man (if any)

By completing this online form, I am submitting the registration and authorizing participation for my Young Man (Student) at the 2014 Men of Vision & Excellence (MOVE) Conference in Naples, FL on October 25, 2014. This acknowledges that as the parent or guardian of the Young Man (Student) attendee, transportation to and from the Conference will be my sole responsibility. I take full responsibility and waive and release from any liability all Conference organizers, all Conference Sponsors, and all parties of the Florida Diversity Council. Student participation in the 2014 Men of Vision & Excellence (MOVE) Conference is fully voluntary. I also grant permission for my son (or grandson, student) to be included in group event photos.

For more details about the 2014 Men of Vision & Excellence (MOVE) Conference, please contact Ameerah Mukayed at [email protected].