San Diego Youth Leadership Conference

Joseph H. Pendleton Youth Leadership Conference, Inc.

PO Box 1494, Fallbrook CA 92088-1494
A Patriotic Education Program of San Diego County Chapters of
The Military Order of the World Wars
And National Sojourners, Inc.
“Attitude is Everything”
From: Board of Directors
To: Prospective Conference Attendees

Subj: SAN DIEGO YOUTH LEADERSHIP CONFERENCE – 2011 Session

The San Diego Youth Leadership Conference is a patriotic education program founded by the
Military Order of the World Wars, and supported by the National Sojourners, Hugh O’Brien
Youth Leadership and Joe Foss Institute organizations. The purpose of the Youth Leadership
Conference is to prepare selected students for leadership roles in their respective schools and
lives. In addition, the students will receive educational material that they are normally not
exposed to in today’s educational system. The program will improve the student’s knowledge of
Leadership, American Heritage and History, and the Free Enterprise System. While in an
educational environment the students will gain life long lasting friendships and connections.

All students must be a volunteer to attend, be an incoming sophomore, junior, or senior in high
school, be of good moral character and sound judgment, and finally have a high school grade
point average of 2.5 or higher on a 4.0 scale.

Tuition for the conference is $150.00. Make checks payable to Joseph H. Pendleton YLC. Mail
to, included with the applications:
San Diego YLC
P.O. Box 1494
Fallbrook, CA 92088-1494

Note: Student Scholarships are available through the sponsoring organizations. Please contact us
at sandiegoylc@gmail.com for more information.

There are only a limited number of available student openings. In order to secure a student billet,
the entire application must be complete, including payment. In order to secure your place,
please submit your package a soon as possible. There are only 50 spots, with 5 alternate spots
open this year.

If you have any questions please feel free to contact us at sandiegoylc@gmail.com and we would
be happy to answer any question you might have.

Thank you for your time, and we hope to see your application soon!

Our Youth are the Nation’s Leaders of Tomorrow 1

 San Diego Youth Leadership Conference
Joseph H. Pendleton Youth Leadership Conference, Inc.
PO Box 1494, Fallbrook CA 92088-1494
A Patriotic Education Program of San Diego County Chapters of
The Military Order of the World Wars
And National Sojourners, Inc.
“Attitude is Everything”
Student Application

Date of Application _________________

Applicant Full Name: ___________________________________________ Age _____ Male _____ Female _____
Last First MI
Home Address: ________________________________________________________________________________
Street City State Zip
Telephone No: ( ) _________________ Sophomore ___ Junior ___ Senior ___

Email Address: ____________________________________________ T-shirt Size: S M L XL XXL

Name of Parent or Guardian: _____________________________________________________________________

Name and Address of Student's School: _____________________________________________________________

_____________________________________________________________

(If traveling by means other than Auto and you expect someone to meet you at your destination, complete the
Following) I will arrive by ______________________ by _____________________ at ______________AM/PM
airport, train station plane, train
by the following mode of transportation ___________________________________________________________
include flight or train information

(Plan your trip to arrive at the conference not earlier than 12:00 PM nor later than 1:00 PM on Sunday of the
first day of the conference)

I certify that this application is complete and that all information is true to the best of my knowledge (Incomplete
applications will be returned).

Signature of Applicant: ______________________________________ Date: _____________________________

School or Sponsoring Organization Recommendation:

"I believe that this student possesses the qualifications to benefit from this leadership conference. The student
possesses the academic qualifications as well as the motivation to become a leader and influence the actions of
others for the benefit of our nation."

Name of School/Sponsor Official: ______________________________________ Title: ______________________

Home Phone ( ) ____________________ Work Phone ( ) ____________________________ ext. _______

Note: Applications must be returned to the sponsoring organization in ample time to process and submit to the
conference director by 17 June 2011. Funds are committed for housing, food services, and other logistic support and
it is to allow sufficient time for processing applications, and the administrative and logistics details in preparations
for the YLC. Applications will not be accepted or refunds made after the dates specified in the brochures.

Our Youth are the Nation’s Leaders of Tomorrow 2

 San Diego Youth Leadership Conference
Joseph H. Pendleton Youth Leadership Conference, Inc.
PO Box 1494, Fallbrook CA 92088-1494
A Patriotic Education Program of San Diego County Chapters of
The Military Order of the World Wars
And National Sojourners, Inc.
“Attitude is Everything”
AUTHORIZATION AND RELEASE FORM
I (we), the undersigned being the natural parents and/or the designated legal guardian(s) or custodian(s) of
__________________________________, a minor aged ________ years, date of birth: ______________ hereby authorize,
consent and contract as follows:

Permission is expressly granted for said minor child to attend the Youth Leadership Conference (YLC) to be held at Camp
Pendleton, California, during the period of 126 June to 1 July, 2011 inclusive, including the necessary travel time, under the joint
sponsorship of the Military Order of the World Wars (MOWW) and/or its affiliates, hereinafter referred to as MOWW.

It is understood that said child was invited to attend the Conference after being selected from among other applicants in a contest
conducted and sponsored by the MOWW, who will supplement the expenses incurred by the child's attendance, including
transportation, tuition, lodging, meals, tours, materials and all Conference activities.

In consideration of the payment of the aforementioned expenses, I (we) hereby release and contract to hold harmless, the
MOWW, and any other cosponsors of the YLC, from any and all liability and/or responsibility for the child's welfare, well-being
and control for the entire period of the Conference, including the day of arrival, and the day of departure from the Conference
site.

This is a voluntary release of liability and complete assumption of risk. I hereby release Marine Corps Base Camp Pendleton
(hereafter “Camp Pendleton”), the United States Marine Corps, the Department of the Navy, the United States Government and
all agencies and instrumentalities thereof, its agents, officers, servants and personnel (hereafter “the government”), from any and
all liability, claims, demands and actions whatsoever resulting from my presence on Camp Pendleton, or my involvement in
social events and actions whatsoever resulting from my presence on Camp Pendleton, or my involvement in social events, tours,
training and living in military quarters aboard Camp Pendleton.

This release applies to myself, and to my parents, spouse, children, guardian, executors, future heirs, assigns, creditors and
administrators. This release of liability includes, but is not limited to claims based on negligence, both passive and active, of the
government arising out of or relating to any loss, damage, illness, death or injury that may be sustained while on Camp
Pendleton. This release also applies to all dangers inherently involved in the event in which I desire to participate. I understand
that the risks involved in this event include, but are not limited to, risks resulting from walking through training areas, rough
terrain, my personal physical condition, vehicles on and around the training areas and lack of hydration.

Known risks aboard military installations include, but are not limited to: (1) injuries or death resulting from strenuous activities;
(2) injuries or death resulting from recreational activities; (3) high volumes of traffic by civilian and military vehicles; (4)
interactions with animals, both wild and domestic; (5) significant distances from recreational areas to medical treatment facilities
or hospitals; (6) potentially hazardous training activities, including but not limited to, range firing, aircraft operations and field
maneuvers; and (7) hazards inherent to firing weapons, including but not limited to being wounded by errant projectiles, being
injured by the target apparatus and exploding ammunition or weapons.

I understand that no special measures have been taken to specifically address the needs, tendencies and care of minor children. I
agree that this release applies, not only to myself, but also to my minor children who accompany me, and to any minor children
entrusted to my care or guardianship.

I further state that I, _____________________have carefully read the foregoing release, know the contents thereof, and sign this
release as my own free act, on behalf of myself and/or my child or children for whom I am authorized to act as legal guardian.

Enclosed is a check for $150.00 payable to the J. H. Pendleton YLC Inc. If the applicant does not arrive at the proper time and
place for the conference, it is understood that this sum will be forfeited.

Date: ______________Signature of Releaser (Student) _______________________________________

_______________________________________ _____________________________________________
Parent signature Parent signature

Relationship: __________________________ Relationship: ___________________________________

Our Youth are the Nation’s Leaders of Tomorrow 3

 San Diego Youth Leadership Conference
Joseph H. Pendleton Youth Leadership Conference, Inc.
PO Box 1494, Fallbrook CA 92088-1494
A Patriotic Education Program of San Diego County Chapters of
The Military Order of the World Wars
And National Sojourners, Inc.
“Attitude is Everything”
MEDICAL HISTORY

FILL IN THE INFORMATION AS COMPLETELY AS POSSIBLE

Date of last complete physical examination (month and year) ____________________________________________

Has it ever been necessary to restrict your physical activities for medical reasons? YES ________ NO _________
If YES, explain in full: __________________________________________________________________________

_____________________________________________________________________________________________

Are you aware of any current health problems? YES ______ NO ______
If YES, explain: _______________________________________________________________________________

_____________________________________________________________________________________________

Are you now under medical care or regularly taking medications? YES ______ NO ______

If YES, explain: _______________________________________________________________________________

_____________________________________________________________________________________________

List all prescription medications: __________________________________________________________________

List all non-prescription medications: ______________________________________________________________

Has there been any significant surgery injury, illness or change in health status since your last physical examination?

YES ______ NO ______

If YES, explain: _______________________________________________________________________________

_____________________________________________________________________________________________

EMERGENCY MEDICAL INFORMATION

If subject to any of the following, check the box and explain in detail:

Allergy to any plant, food or animal: _______________________________________________________________

Allergy to any drug or insect toxin: ________________________________________________________________

Any condition requiring regular medication or diet or special care ________________________________________

_____________________________________________________________________________________________

Asthma _________ Convulsions _________ Heart Trouble ________ Diabetes _______ Bleeding Disorder ______

Other, Explain: ________________________________________________________________________________

_____________________________________________________________________________________________

Our Youth are the Nation’s Leaders of Tomorrow 4

 San Diego Youth Leadership Conference
Joseph H. Pendleton Youth Leadership Conference, Inc.
PO Box 1494, Fallbrook CA 92088-1494
A Patriotic Education Program of San Diego County Chapters of
The Military Order of the World Wars
And National Sojourners, Inc.
“Attitude is Everything”
HEALTH AND MEDICAL FORM
Name: __________________________________________ Date of Birth: ___________________ Age: _________

Address: _____________________________________________________________________________________
Street City State Zip

IN CASE OF EMERGENCY, NOTIFY: Name: _______________________________Relationship:___________

Address: _____________________________________________________________________________________
If different from above Street City State Zip

Telephone (Home): ______________________ Office: ________________________ FAX: ___________________

Health Insurance Company: ______________________________________ Policy Number: __________________

Family Physician: ______________________________________________ Telephone: ______________________

AUTHORIZATION TO CONSENT TO TREATMENT OF A MINOR

THIS FORM MUST BE SIGNED BY PARENT OR GUARDIAN IF PARTICIPANT IS UNDER 18.

I (we), the undersigned parent(s) (or guardian(s)) of the above named minor, do hereby authorize the Military Order
of the World Wars Youth Leadership Conference transport and obtain diagnosis or treatment and Hospital care
which is deemed advisable by, or which is to be rendered under the general or special supervision of a Physician or
Surgeon licensed to practice in the State of California.

I hereby authorize emergency medical treatment in the event of injury or illness. I also authorize trained health care
providers, including but not limited to physicians, nurses, nurse practitioners and hospital corpsmen, to administer
routine and/or emergency medicines and treatments as needed. I hereby release these health care providers from all
liability for acts associated with providing me with emergency medical care.

It is understood that I will surrender all prescription and non-prescription medications to the Conference Directors
upon arrival. The prescription medications will be controlled by the Conference Directors and provide the student
access to the prescription medications as the doctor has directed.

It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being
required, but is given to provide authority and power on the part of our aforesaid agent in the exercise of his best
judgment may deem advisable. This authorization will be effective from the first through the last day of the
Conference, unless sooner revoked in writing and delivered to said agent.

Date: _______________________ Signature of Releaser (Student): _______________________________________

Signature of Parent/Guardian: ________________________________________

Signature of Parent/Guardian: ________________________________________

Emergency Home and/or Cell Phone No: __________________________________

Our Youth are the Nation’s Leaders of Tomorrow 5