2018 Colorado Springs Leadership Symposium Application
1. Please complete the application below to register for the 2018 Colorado Springs Leadership Symposium. For more information on the program, visit
2. The red * means that the field is required.
District of Columbia
U.S. Overseas Military Base
Northern Mariana Islands
When were you born? (MM/DD/YYYY)
To comply with legal requirements, we must ask for your birthdate.
High School Graduation Year
Please enter a 4-digit year (example: 2015)
Parent/Guardian First Name
Parent/Guardian Last Name
Referring Teacher Information
Please include the contact information for a social studies teacher (history, government, civics, economics, etc.). We may contact this teacher to provide a reference for you.
Teacher First and Last Name
Teacher Email Address
Participant Publicity Release
I, the undersigned, in consideration of possible publicity and other valuable consideration, receipt of which is hereby acknowledged, hereby authorize The Bill of Rights Institute and its affiliates, designees, assignees, transferees, licensees, grantees and any entities or persons acting on behalf of any of the foregoing (collectively, “Grantees”) to film, photograph and otherwise record my likeness, voice and any other form of my identity, and grant Grantees the right to create, reproduce, alter, modify, publish, display, sell, transfer, exhibit and use my voice, likeness, and any other form of my identity in any manner (including without limitation advertising, promotion, and merchandising) or form, including without limitation all video, audio, digital, and print formats and any other media now known or hereafter created, including without limitation use via computer, the Internet, films, DVDs, video tapes, audio tapes, digital audio files, digital image files, photographs, prints, copies, facsimiles and electronically captured images thereof, without limitation as to method of reproduction or exhibit and without any territorial or time restrictions.
Further, I hereby relinquish, give, transfer, and assign to Grantees all right, title, copyright and interest I may have in the finished product contemplated by this Release, agree that any and all materials created by or on behalf of Grantees are the property of Grantees, and I waive any right of review or inspection. I agree that no other material needs to be submitted to me for any further approval, and Grantees shall be without liability to me or any person for any distortion or illusionary effect resulting from the publication or dissemination of any likeness, audio recording, or other indicia of my identity.
I state further that: (a) I am of legal age and capacity; (b) I acknowledge that nothing herein requires Grantee(s) to use my likeness as described herein or elsewhere; (c) I acknowledge that no compensation or consideration will be provided to me for the rights and releases granted herein, other than the potential publicity; (d) I have read, or have had read to me, this Release and have had the opportunity to ask questions before its execution, and I am fully familiar with and understand its contents; and (e) I hereby irrevocably release Grantees from any and all liability based upon, arising out of or in any way related to this Release or the exercise of the rights granted herein.
I have read this statement
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