Youth & Government REGISTRATION FORM

Transcription

1 Youth & Government REGISTRATION FORM CHOOSE 1 of 2 PAYMENT OPTIONS 1. Enclosed is my check* or credit information to pay in full: Facility Members - $1,250 Program Members** - $1,450 * If using a checking account, a voided check is required. OR 2. A utomatic draft on the 3rd of the month (by credit card* or debit card): Facility Members - 2 payments (October & December / $625 per month) Facility Members - 4 payments (October - January / $ per month) Program Members** - 2 payments (October & December / $725 per month) Program Members** - 4 payments (October - January / $ per month) * Discover not accepted for draft payments. ** $25 Program Membership fee required. Name on Account: Card Type: Visa MasterCard Discover Amex Account #: Exp. : I (we) hereby authorize Northwest YMCA, hereinafter called YMCA, to initiate debits to the bank/credit account indicated above and to debit the amounts thereof to my bank account indicated above. This authority is to remain in full force and effect until the YMCA has received written notification from me of its termination in such time and in such manner as to afford the YMCA a reasonable opportunity to act on it; or until the YMCA has sent me 15 days written notification of the YMCA's termination of this agreement. Parent Signature: Child's Name: To register: Mail completed form to Northwest YMCA (Attn: Teddy Evans, Alves Dr, Cupertino, CA 95014) or return it in person.

2 NORTHWEST YMCA California YMCA Youth & Government Delegate Emergency Information Form DELEGATE INFORMATION Cell Vegetarian: Yes No of Birth: Sex: M F School: Grade: Previous Participation: T&EI T&EII Sac Spring PARENT/GUARDIAN INFORMATION Daytime Evening Daytime Evening EMERGENCY INFORMATION Emergency Contact Name: Relationship: Doctor's Name and Group: Insurance Policy Group, Name and Dentist's Name and Group: Insurance Policy Group, Name and List current prescription medication (separate medication release form required): Describe any allergies, physical restrictions or special considerations: If there are no restrictions, check here:

3 YMCA OF SILICON VALLEY Teen Independent Dismissal Consent For Campers Entering 7-10th Grade: Parent Consent Agreement: This section is only for Teen Camp participants and their parents/guardians. Check the Teen Camp activities below in which you would like your child to be involved. Independent Dismissal: Youth 12 years and older may sign themselves in and out of camp; however, for your child s safety, we require parental/guardian consent for this privilege. Yes, my child may sign himself/herself in and out. No, my child may not sign himself/herself in and out. Independent Field Trip Supervision Consent: Youth are given the opportunity to divide into groups of four or more to explore what specific highlight field trips have to offer, independent of staff. Campers must adhere to strict guidelines listed below: All campers will have an option to stay with YMCA staff during the highlight field trip. All campers will remain in the pre-determined boundaries during all highlight field trips. All campers will travel together in groups of four or more. All campers will be notified of a pre-assigned base location where they will check in with YMCA staff every 90 minutes or in case of an emergency. YMCA staff will be available at base location throughout the highlight field trip. Campers will be provided with emergency contact instructions and a list of numbers in case of any emergencies. YMCA staff will carry communication devices. Failure to abide by all YMCA rules will result in the suspension of self-supervision privileges (for both the remainder of the activity and potentially for future YMCA activities). Yes, my child may participate in independent field trip supervision while adhering to regular check-ins. No, my child needs to have constant adult supervision. PARENT/GUARDIAN SIGNATURE: DATE:

4 NORTHWEST YMCA California YMCA Youth & Government Release Form and Code of Conduct RELEASE FORM: Name of minor I, the undersigned parent/person having legal custody/guardianship of the above said minor, give permission for the minor to participate in the YMCA program described above. The minor is physically able and mentally prepared to participate in all activities as described in the announcement for the program. In consideration of said minor being permitted to enter any branch of YMCA of Silicon Valley ( YMCA ) for observation, use of facilities and/or equipment, or participation in the above or any program, I, on behalf of myself (as parent, guardian, coach, aide, spectator or participant) hereby: 1. Acknowledge that (i) I have read this document, (ii) I have inspected the YMCA facilities and equipment, (iii) I accept them as being safe and reasonably suited for the purposes intended and (iv) I voluntarily sign this document. 2. Release YMCA, its directors, officers, employees and volunteers (collectively Releasees ) from all liability to me for any loss or damage to property or injury or death to person, whether caused by Releasees or otherwise and while such minor is in or near any YMCA branch. 3. I agree not to sue Releasees for any loss, damage, injury or death described above and I will indemnify and hold harmless Releasees and each of them from any loss, liability, damage or cost they may incur due to said minor s presence in, upon or near the YMCA branch; whether caused by the negligence of Releasees. 4. I assume full responsibility for, and risk of, bodily injury, death or property damage due to the negligence of Releasees or otherwise. 5. I do hereby authorize the YMCA as agent for the undersigned to consent with respect to said minor, to any x-ray examination, anesthetic, medical, dental, or surgical diagnosis or treatment, and hospital care which is deemed advisable by, and is to be rendered under general or special supervision of, any physician and surgeon licensed under the provisions of the California Medical Practice Act on the medical staff of any hospital, whether such diagnosis or treatment is rendered at the office of the physician or at the hospital. I understand that the YMCA is not responsible for costs incurred for medical care. I intend this document to be as broad and inclusive as is permitted by the laws of the State of California, if any portion hereof is held invalid, I agree the balance shall continue in full force and effect. Parent / Guardian Signature CODE OF CONDUCT I have read and understand the California YMCA Youth & Government Code of Conduct, and I accept the responsibility for my child s adherence to it. I also understand that if my child violates the Code of Conduct and is expelled from the program, that I am responsible for his/her immediate transport from the conference or YMCA function. This transport shall be done at my expense. Parent / Guardian Signature I have read and understand the YMCA Code of Conduct and I agree to follow it. I understand that failure to adhere to the Code s minimum standards of conduct may result in my immediate expulsion from the California YMCA Youth & Government Program. Delegate Signature

5 YMCA of SILICoN VALLeY Photo and Video/Audio Recording Release I am 18 years of age or older and, if not, my Mother/Father/Legal Guardian has also signed below. For my participation in activities to be conducted by YMCA of Silicon Valley, I hereby give my permission and consent, now and for all time, to YMCA of Silicon Valley, the National Council of Young Men s Christian Associations of the United States of America (YMCA of the USA) and third parties collaborating with YMCA of Silicon Valley and/or YMCA of the USA to make, reproduce, edit, broadcast or rebroadcast any video film, footage, sound track recordings and photo reproductions of me and/or my narrative account of my experience at YMCA of Silicon Valley, for publication, display, sale or exhibition thereof in promotions, advertising and legitimate business uses without any compensation to, and/or claim, by me. I may, or may not be, identified in such reproductions; however, I shall not be stated by name to have endorsed any particular commercial products or commercial services. I further agree to the following: - Any video film, footage, sound track recordings, and photo reproductions of me and/or my narrative account of my experience at YMCA of Silicon Valley, I authorize, according to this Release, shall belong to YMCA of Silicon Valley, YMCA of the USA and third parties collaborating with YMCA of Silicon Valley and/or YMCA of the USA. Therefore, they will have full right of disposition of any video film, footage, sound track recordings and photo reproductions of me and/or my narrative account of my experience YMCA of Silicon Valley; - Any video film, footage, sound track recordings and photo reproductions of me and/or my narrative account of my experience YMCA of Silicon Valley will not be subject to any obligation of confidentiality and may be shared with and used by YMCA of Silicon Valley, YMCA of the USA and third parties collaborating with YMCA of Silicon Valley and/or YMCA of the USA; - YMCA of Silicon Valley, YMCA of the USA and third parties collaborating with YMCA of Silicon Valley and/or YMCA of the USA shall not be liable for any use or disclosure to a third party of any video film, footage, sound track recordings and photo reproductions of me and/or my narrative account of my experience at YMCA of Silicon Valley; and - YMCA of Silicon Valley, YMCA of the USA and third parties collaborating with YMCA of Silicon Valley and/or YMCA of the USA shall exclusively own all known or later existing rights to worldwide and shall be entitled to the unrestricted use any video film, footage, sound track recordings and photo reproductions of me and/or my narrative account of my experience at YMCA of Silicon Valley for any purpose without compensation to me. I agree that my consent and this release are irrevocable. I hereby release and discharge YMCA of Silicon Valley, YMCA of the USA and third parties collaborating with YMCA of Silicon Valley and/or YMCA of the USA from any and all claims in connection with the uses and reproductions of any video film, footage, sound track recordings and photo reproductions of me and/or my narrative account of my experience YMCA of Silicon Valley as described herein. Signature Print Name Address Age I am the Mother/Father/Legal Guardian of contained herein, I hereby consent to the foregoing on behalf of my minor child. (child s name). For the consideration Signature of Mother/Father/Legal Guardian