STUDENT INFORMATION
& INTEREST FORM 2015
Name:
WIN:
Campus/Local Address:
City:
Zip:
Preferred E-mail:
Preferred Phone:
Major:
Tent. Graduation Date:
T-Shirt Size:
LE courses I have taken/am taking:
Dietary Needs:
(If any information changes throughout the year, please notify the LI office so you will receive all information.)
I plan to: (Check all that apply.)
1. Be involved in LI extra-curricular activities
2. Take/taking a Leadership Course(s)
3. Pursue a Leadership Studies Certificate
4. Pursue a Leadership Studies Minor
5. Other:

Please list any licenses/certifications/special skills (i.e. lifeguard, CPR/BLS, juggler, tumbling, garage band, ukulele etc.)
Please rank your preferred method of communication.
Texting
Facebook
phone call
Twitter
GroupMe
remind
email
Instagram
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ASSUMPTION OF RISK AND RELEASE
I, _______________________________________, certify I am 18 years of age or older and wish to participate in Washburn University
Leadership Institute events, hereafter “Event.”
Description of Event – student events held in conjunction with the Washburn University Leadership Institute, on or off
Washburn University campus between July 1, 2015 and June 30, 2016.
I understand and agree there is a risk of injury associated with my participation in Event which cannot be eliminated
regardless of the care taken to avoid injuries. Specific risks range from (1) minor injuries such as scratches, bruises and
sprains; (2) major injuries such as eye injury or loss of sight, fractures, back injuries, heart attacks and concussions; and, (3)
catastrophic injuries including paralysis and death.
I have read the previous paragraph and I know, understand and appreciate these and other risks inherent in Event.
In consideration of my participation in Event, I hereby freely and voluntarily
1. accept all risks associated with my participation in Event; and,
2. release and hold harmless Washburn University, its officers, agents, employees from and against any damage, loss,
claim or injury arising out of or resulting from my participation in Event.
I have read this Assumption of Risk and Release, fully understand its terms and understand I am giving up substantial
rights, including my right to sue. I hereby acknowledge I am signing this Assumption of Risk and Release voluntarily
and intend this to be a complete and unconditional release of all liability to the greatest extent permitted by law.
Date:
Student Signature: __________________________________
WIN:
PHOTO RELEASE
I, _________________________________________________, being of lawful age, hereby freely and willingly give Washburn University of
Topeka and its authorized agents and employees the absolute right and unrestricted permission to copyright, use and/or publish
my photographic likeness in any form for the purpose of advertising, for endorsing or promoting such University in any print or
electronic media.
I waive any right that I may have to inspect and approve the finished product or the copy that may be used in connection with
the likeness or the use to which it may be applied. It is understood that my name may or may not be used in conjunction with
the photographic likeness.
It is understood that no compensation has been paid and that no fee or compensation shall be due to me for my giving permission
to such University for the use of my photographic likeness for the purpose stated above.
_____________________
Date
Name
University Relations
1700 SW College
Washburn University
Topeka, KS 66621
785-670-1154
www.washburn.edu
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Name: ________________________
Email: _______
___
WIN: _________________________________
_______________________________
I am interested in: (Check all that apply.) All teams will be involved in the Leadership Challenge Event™ and all
students are encouraged to volunteer.
⧠ Communications Team: Directors – Jack Van Dam and LCE™ Ryan Kelly
⧠ Social Media – Promotes the Leadership Institute events on social media websites in conjunction with the
Social Media Team Leader (Leah Coons).
⧠ Newsletter – Provides the Newsletter Team Leader (Abraham Pfannenstiel) assistance in the compiling,
writing, and editing of the monthly eNewsletter and annual summer newsletter
⧠ Marketing - Assists the Marketing Team Leader (Alexis Yelland) in promotion of WULI events through the
creation of various marketing tools including banners, invitations, posters, etc.
⧠ Web/Technology – Updates and provides the WULI web and technology needs through the Team Leader
(Darria Dennison) for the Leadership Challenge Event™ and Leadership Institute. Leads and organizes
photography/videography of the Leadership Institute and the Leadership Challenge Event™ functions
throughout the year.
⧠ Community Outreach Team: Directors – Leanna Willer and LCE™ Katelyn Rollins
⧠ Community Liaison - Brings awareness to WULI about community engagement opportunities in Topeka, in
conjunction with the Team Leader (Holly Johnston). Communicates with WULI alumni about involvement in
events of the LI. Maintains contact with community professionals, the WULI advisory board and other potential
community partners. Provides LCE™ support through promoting sponsorship opportunities for the event to the
community.
⧠ Volunteer Coordinator – Plans, with the Team Leader (Jessica Knieff), and promotes service opportunities
for the Institute on campus and throughout the Topeka community. Coordinates Leadership Challenge Event™
volunteer acquisition and training.
⧠ Leadership Labs/PIC - Helps create and plan Leadership Labs for the members of the Institute along with
the Leadership Institute Director and Team Leader (Caroline Clark). Involve WULI students in the PALS in the
Community (PIC) program and plan PIC events.
⧠ Programming: Directors – Marissa Dake and LCE™ Machaela Geither
⧠ K-12- Assist the Team Leader (Jenny Lieurance) in leadership programs and outreach to students in K-12
schools, manage tabling opportunities at Washburn functions, and organize and implement the Scholarship
Interview Day process. Assist with the team acquisition of the Leadership Challenge Event™.
⧠ Socials – Plan and implement All-Institute socials with the Socials Team Leader (Kassidy Forshey).
⧠ Homecoming/Campus Affairs – Coordinates LI involvement in all WU events including homecoming and
the LI tailgate party with the Team Leader (Natasha Martinez). Aids the LI Parade Coordinator (Dani Bradrick)
on the day of the Homecoming Parade. Assists in getting the WU community involved in the LCE™ through
sponsorships and volunteers.
⧠ Orientation - Plans spring orientation with the Team Leader (Kimberly Euler).
⧠ Banquets- Works with the Team Leader (Lauren Overkamp) to plan and organizes WULI banquet events
including LI Family Day, Spring Banquet, and the LCE™ food needs including LCE™ Launch, banquet, ice cream
social, and snacks for hospitality and team rooms.
Return this form to receive your WULI Fall Orientation t-shirt
and to be contacted by your team leader concerning activities, events and meetings.
Document1
Updated 2/8/2016
Document1
Updated 2/8/2016