I AM Retreat 2017 SCHOLARSHIPS Your Name* First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Daughters NamePhone*Email* Release, Waiver and Consent Form I am the parent/legal guardian of the below-named "Participant" who is, with my permission, participating in an I Am Girl Event, sponsored by Girl Country, LLC. In the event that I am not immediately available, should the Participant suffer a serious or life-threatening injury for which emergency medical treatment may be necessary, I hereby authorize an appropriate adult staff member, designated by Girl Country, LLC. to engage qualified medical personnel to initiate any necessary medical treatment or care. In the event of such an injury, it is understood that Girl Country, LLC. will use all reasonable efforts to notify me (or the emergency contact listed on my child's application), where practical, prior to initiating medical treatment for any such injury to the Participant. Should neither party be available, an appropriate staff person will contact appropriate medical personnel to initiate the necessary medical treatment, and I hereby give permission to any such physician or other medical personnel to provide such medical treatment such individual deems medically appropriate. I agree that medical treatment for any other type of injury may be coordinated by Girl Country, LLC. in consultation with appropriate medical personnel. I understand and agree that I am responsible for all medical care expenses incurred to treat the Participant's injuries including, without limitation, physician, hospital, lab, drug and device expenses. The following policies or coverage are available to cover the cost of medical care to treat any injury incurred by the Participant. My child has my permission to participate in the I Am Initiative Event, under supervision with Girl Country, LLC. & staff members: On behalf of the Participant, the Participant's parents, and/or legal guardians, I hereby give approval of the below-named Participant's participation in any and all programs and activities sponsored or provided by the I Am Initiative and Girl Country, LLC., and do hereby waive, release, absolve, forever discharge, and agree to hold harmless the organizers, supervisors, participants, and persons involved in the operation, organization, sponsorship, supervision or participation of these activities and programs, including without limitation, the I Am Initiative, Girl Country, LLC., and all their respective directors, volunteers, contractors and subcontractors, for, from, and against any claim or cause of action of any nature whatsoever that may be available to the Participant or her parents and/or legal guardians, arising out of any injury, accident or illness to the Participant, arising in any way out of or in connection with the Participant's participation in such programs and activities. I understand this is non-refundable/transferrable and I agree to participant taking part in such programs and activities. I grant approval of Girl Country, LLC., its and it's representatives the right to take photographs of the Participant during the event. I authorize Girl Country, LLC., its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that Girl Country, LLC. may use such photographs of the Participant for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.I have reviewed the waiver form and agree to the terms. Yes, I Agree There are different types of scholarships available. Please connect with me on your needs and we'll come up with a solution. To start, what retreat would your daughter attend. 2-3rd Grade/4-6th Grade/7-9th Grade? We'll be able to work something out with you!*Would you like to receive occasional updates from us? 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