Manhood 101 Registration – The Congressional Award

Manhood 101 Registration Form

Name*
First Last
Address*
Street Address City
State*
State/Territory
Address ZIP / Country*
ZIP / Postal Code Country
Phone*
Email*
Enter Email Confirm Email
Date of Birth*
Please only register if you are at least 13 1/2 years of age AND not yet had your 24th birthday. We cannot accept registrations outside this age range!
MM slash DD slash YYYY
Parent/Guardian Email
Required for registrants under the age of 18. Optional for adults.
Enter Email Confirm Email
Parent/Guardian Name
First Last
Gender*
Gender does not influence eligibility. We collect demographic information for the sole purpose of reporting (grants, yearly reports to Congress, etc.). If the participant is uncomfortable reporting this information, they may choose "Identify as other/Prefer not to report."
- Female
- Male
- Gender Variant/Non-Conforming
- Other/Prefer not to report
Race/Ethnicity*
Race and/or ethnicity in no way influence eligibility. We collect demographic information for the sole purpose of reporting (grants, yearly reports to Congress, etc.). If the participant is uncomfortable reporting this information, they may choose "Unknown/Prefer not to report."
Omega Psi Phi Chapter (City)
Current School
Advisor's Name*
You must choose an Advisor who will serve as your mentor for The Congressional Award. This can be anyone BESIDES your parents, relatives, or peers.
First Last
Advisor's Address*
Street Address City State / Territory ZIP / Postal Code
Advisor State*
State/Territory
Advisor Address*
ZIP / Postal Code Country
Advisor's Email*
Enter Email Confirm Email
Advisor's Phone
How did you hear about The Congressional Award?*
Waiver and Agreement*
I agree to the following Congressional Award ("Program") rules and requirements:
• I will select the activities I will perform in order to earn a certificate or medal.
• I will not attempt to perform any activity until I have made certain that I can perform it safely.
• No one is authorized by the Program to: (i) advise as to the safety of any activity or as to whether I am prepared to perform it safely, or (ii) supervise or exercise any control or authority over me or any other participant.
• I hereby release and hold harmless each of the individuals and legal entities involved in the Program from any and all liability of any kind for any injury I might suffer while performing any activity in connection with the Program.
• Information about me and my participation in the Program may be publicized by the Program.
• This agreement shall remain in effect as long as I am participating in the Program.
Participant Signature*
Parent/Guardian Signature
(Required for participants not considered adults under state law, generally those under 18 years old). I am a parent or legal guardian of The Congressional Award participant listed above. We have read the foregoing Waiver and Agreement and agree on behalf of ourselves and the participant to the terms thereof. We will assure ourselves that the participant is aware of the risk involved in each activity and we take full responsibility in lieu of the Program for each activity.

Manhood 101 Registration Form

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