Students In Action

SIA STUDENTS:  Please fill out the infomation below to complete your Students In Action leadership conference registration for the 2015-2016 school year. If you are under 13, please see your Advisor for a parental permission form.

IMPORTANT:  If you are completing this form for multiple people, please enter a separate email address for each individual you are registering.  Thank you.

HS Graduation Year*
Grade Level*
Date of Training*
* *
City* State*
Postal Code* Country*

Please select your birthdate below. If you don't see your year of birth or you are under 13, please see your Advisor for a parental permission form.

Date of Birth*
Have you attended a previous SIA leadership conference?*


I, the undersigned, grant permission to Jefferson Awards Foundation (JAF) to use the name, photograph, voice, video image, and/or verbal or written statements of me (if I am over 13 years of age), as well as any written or visual content posted on social media in relation to the JAF programs. This permission is not required for students to participate; however, students are encouraged to participate in social media activities which may include their content being posted or otherwise shared via JAF social media channels. No compensation is due for any such use. I understand that the content referenced above may be posted to social media sites of JAF, and will be used by JAF only in the context of promoting and participating in JAF youth programs: Students In Action, Lead360, Globechangers.

Please check the box below to show your marketing release consent*

Liability Release

By providing my initials in the box and signing this Release below: I agree that JAF and each of their respective agents, subcontractors, representatives, affiliates, subsidiaries, officers, directors, employees, legal advisors and advertising, promotion and fulfillment agencies shall not be liable for any injuries, losses, or damages of any kind arising in connection with or as a result of JAF use of the aforementioned content on its social media channels, including without limitation, personal injury, death, property damage, and claims based upon publicity rights, defamation, libel or invasion of privacy.

Please check the box below to show your liability release consent*
* *
Medical Conditions or Special Conditions (list all clearly below) If none, please type "None":*