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I _______________________________ (Parent or Legal guardian) understand that the participation of __________________________________ (participant) in Omega Educational Foundationís 9th Annual Youth Leadership Conference. The events of the youth 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 Youth Leadership Conference.

I understand that signing this release form is an acceptance to the above and a prerequisite to participate in the 9th Annual Youth Leadership Conference. In addition, it is your responsibility to inform the Program Coordinator of this program of any extenuating circumstances (medical, physical, or mental) that affects the well being of the participant or might detract from learning experiences of the other participants. 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:________________________________________________________


City, State, Zip: ______________________________________________________________________

Phone Number:_________________________________________________________________________

Emergency Phone for Day of the Event: ____________________________________________________

PLEASE LIST ANY ALLERGIES OR MEDICAL CONDITIONS YOUR CHILD HAS:________________________________________________________________________________


Please return to the address below:

Omega Educational Foundation

9th Annual Youth Leadership Conference

P.O. Box 91302

Los Angeles, California 90009

Please contact Ricky Lawrence Lewis (323) 658-2995 if you have any questions.