Omega Psi Phi Youth Leadership Conference

FREE! LUNCH, BOOK, T-SHIRT and BACKPACK

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20 Anniversary!

Theme Manhood, Scholarship, Perseverance and Uplift

OMEGA EDUCATIONAL FOUNDATION 501c3

OMEGA PSI PHI FRATERNITY, INC. Tau Tau Chapter

20th ANNUAL YOUTH LEADERSHIP CONFERENCE Having touched the lives of over 4500 young men over the last 19 years, this youth conference is designed to focus on pertinent issues facing males, including Self Esteem, Goal Setting, Health & Wellness, Social & Personal responsibility, Family unity, Academic growth and development, and Conflict Resolution. This conference continues to provoke our youth to think, achieve and be leaders.

SPACE FOR THIS YOUTH LEADERSHIP CONFERENCE IS OPEN TO THE FIRST 600 MALES (AGES 8-18). NO ON SITE REGISTRATION. NO COST TO PARTICIPATE! NO COST TO PARTICIPATE!

Saturday, October 19, 2013 8:00 a.m. - 2:00 p.m.

Location: University of Southern California (USC)—Taper Hall CONTACT: RICKY LAWRENCE LEWIS, for registration forms: 323.658.2995—rickylewis@earthlink.net www.omegaeducationalfoundation.org

OMEGA EDUCATIONAL FOUNDATION 501c3 P O Box 91302 Los Angeles, California 90009 20th Annual YOUTH LEADERSHIP CONFERENCE

Application

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20 Anniversary!

Participant Name:______________________________________ Age:____ Grade____ Street Address:______________________________________________________________ City/State/Zip:______________________________________________________________ Parent/Guardian: ____________________________________________________________ Telephone Number: (

)______________

Cell #______________ T-Shirt Size________

Brief description of yourself and future goals: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ School you attend: __________________________________________

Last Semester GPA_________

Activities (list as many as you like): _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Did you attend our Youth Leadership Conference last year?

Yes ______ No _______ Plans to attend College: Yes______ No_____ If yes, where would you apply for college: __________________________________________________________________________________ Why are you attending this 20th Annual Youth Leadership Conference? _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

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20 Anniversary!

PARENT/PARTICIPANT RELEASE FORM

Theme Manhood, Scholarship, Perseverance and Uplift I _______________________________ (Parent or Legal guardian) understand that the participation of __________________________________ (Participant) in Omega Educational Foundation’s 19th Annual Youth Leadership Conference. The events of the Youth Leadership Conference will be in a classroom setting. Omega Educational Foundation will bear the full cost of food for each participant in the event.

Parent /Guardian must provide Transportation to and from the 20th Youth Leadership Conference.

I understand that signing this release form is an acceptance to the above and a prerequisite to participate in the 20th Annual Youth Leadership Conference. In addition, it is your responsibility to inform the Program Coordinator of this program of any extenuating circumstances (medical, physical, diet, or mental) that affects the well-being of the participant or might detract from learning experiences of the other participants. The Omega Educational Foundation may photograph and video my child during the program and I hereby consent to the use of these photos and videos by the Omega Educational Foundation. Parents and Guardians are also responsible for ensuring each participant has no weapons, drugs, or any illegal substance that causes threat to him or the general body of participants.

Signed: _____________________________________________ Date:____________________________ (Parent or Legal Guardian)

Print Below: Name of Parent or Legal Guardian:________________________________________________________ Address:______________________________________________________________________________ City, State, Zip: ______________________________________________________________________ Home Phone Number:___________________________________ Cell #__________________________ E-mail Address: ___________________________________________________________________ Emergency Phone for Day of the Event: ____________________________________________________

PLEASE LIST ANY ALLERGIES, DIETARY RESTRICTIONS, OR MEDICAL CONDITIONS YOUR CHILD HAS:_______________________________________________ Please return to the address below: Omega Educational Foundation 20th Annual Youth Leadership Conference P.O. Box 91302 Los Angeles, California 90009 Please contact Ricky L. Lewis (323) 658-2995 or rickylewis@earthlink.net if you have any questions.