TEEN LEADERSHIP DEVELOPMENT PROGRAMS REGISTRATION FORM

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1 TEEN LEADERSHIP DEVELOPMENT PROGRAMS REGISTRATION FORM Teen First Name Last Name Please check the box for the program(s) that you are wanting to register for the school year and include your deposit(s) when you turn in these forms. Please initial next to the payment option you prefer. Talk with Don Brevik if you would like to set up a monthly payment option. We can work with you to set up a payment plan that works for your family so reach out with any questions. Additional program information and/or program specific paperwork (if required) will be mailed home upon receiving the deposit for program(s) you register for. PACIFIC REGION CONFERENCE (Grades 9-12) COST: $285 $55 Deposit Due 9/28/18 I will pay remaining balance of $230 by 11/16/18 of $230 is paid by 11/5/18 YLD CLUB (Grades 7-12) COST: $90 $30 Deposit Due 9/28/18 I will pay remaining balance of $60 by 11/29/2018 of $60 is paid by 11/5/2018 YLD CONFERENCE (Grades 7-12) COST: $320 $60 Deposit Due 3/29/19 I will pay remaining balance of $260 by 5/10/19 of $260 is paid by 5/5/19 YOUTH AND GOVERNMENT (Grades 8-12) COST: $445 $75 Deposit Due 10/26/18 I will pay remaining balance of $370 by 4/5/19 of $370 is paid by 4/5/19 KIDS NIGHT OUT TEEN LEADER (Grades 8-12) KNO application required in addition to this paperwork. Teens choosing to be a KNO Program Participant/Leader must be enrolled in one of the above programs as well. Select only one training you plan to attend Fall KNO Training September 8-9, 2018 (This training is an overnight at the Y) Winter KNO Training January 13, 2019 (This training is a one day training at the Y) SUMMER OF SERVICE (Going into grades 10-12) COST: $700 $100 Deposit Due 12/21/2018 Additional SOS registration forms required All deposits paid secure your spot in the program(s) and are deduced from the total fee of the program(s). Cost should never be a barrier to participate in any of the Teen Leadership Development programs. Financial assistance is available.

2 TEEN LEADERSHIP DEVELOPMENT PAYMENT FORM FINANCIAL ASSISTANCE: Financial assistance is provided to everyone on a need basis and allows access to all these programs. If we can serve your family in this way, please complete a Financial Assistance Application online today at ymcapkc.org or contact Don Brevik for an application. PAYMENT METHOD Check (made payable to YMCA) Kids Night Out Credit (if available) Credit Card (Visa, Mastercard, American Express, Discover) Amount to be charged on card (for deposits): $ Name on Card: Card Number: Cardholder s Signature: Expiration Date: Date: ACKNOWLEDGEMENT OF FINANCIAL RESPONSIBILITY PLEASE READ AND EACH STATEMENT I accept financial responsibility for fees incurred throughout the program(s) I am registering my teen for. I authorize the YMCA of Pierce and Kitsap Counties to charge my credit card, if applicable, for deposit of program(s) I am registering my teen for. I understand that deposit(s) paid for program(s) are non-refundable. I acknowledge that all fees, including deposit, are geared toward specific program costs. I understand the fees for the program(s) are due according to the payment schedule set forth. I understand that any Kids Night Out teen credit earned may be applied toward any outstanding balance upon request either verbally or written by parent/guardian or my teen. I understand that a written notice of cancelation, with parent/guardian signature is required, if participant is under the age of 18, and that termination from any program requires past payments that are due, according to specific program payment schedule. I understand payment expectations and have chosen my payment method. I agree to abide by all policies in place, and failure to uphold my payment arrangements will result in cancellation of registration and program. I understand that a copy of this registration form will be sent to me as confirmation of registration for any of the YMCA Teen Leadership Development Programs, in addition to a receipt for my deposit/payments made and a copy of the program payment schedule.

3 YMCA OF PIERCE AND KITSAP COUNTIES Teen Leadership Programs Health Form This form will be kept on file until your teen graduates or is no longer participating in Teen Leadership programs. Teen Full Name Birthdate Age Grade Shirt Size Address City Zip Code Teen Cell Number Teen Address Primary Parent/Guardian Full Name Home Phone Number Work Phone Number Secondary Parent/Guardian Full Name Home Phone Number Work Phone Number Date of Birth Cell Phone Number Parent Address Date of Birth Cell Phone Number Parent Address Additional Contacts If the above are unreachable those listed below will be contacted in case of illness/behavior Name Relationship to teen: Home Phone: Work Phone: Cell Phone: Name Relationship to teen: Home Phone: Work Phone: Cell Phone: Insurance Information Is participant covered by medical/hospital insurance? No Yes (please indicate insurance carrier) Insurance Carrier/Plan Name Insurance ID for policy holder Group Number Name of Insured Relation to participant Family Physician s Name Family Dentist/Orthodontist's Name Phone Phone Is the participant on any medication? No Yes Does the participant have any food/drug allergies or dietary restrictions? No Yes Does the participant have any medical concerns? No Yes Please check the boxes that you approve to be administered for any common ailments: Tums Claratin Advil Tylenol 1% hydrocortisone cream Liquid cough suppressant Cough drops Benadryl, 25mg & cream Decongestant Pepto-Bismol Antibiotic Cream Bee sting swabs

4 PARENT/GUARDIAN AUTHORIZATION PLEASE READ AND EACH STATEMENT AND RETURN ALONG WITH REGISTRATION FORM Teen Name As the parent/legal guardian, I give full authorization to the YMCA of Pierce and Kitsap Counties staff or designated adult leaders to secure medical care or treatment for the participant named on this form. In the event my teen is injured, I give YMCA first-aid and CPR-certified staff authority to provide basic first-aid and CPR as the situation requires, including splinter removal, as necessary and/or if my teen becomes seriously ill or injured and I cannot be reached. I grant my permission for any medications that I approved listed on the front side of this form, to be administered to my teen for common ailments. I understand that this treatment may include assistance from the nearest physician, medical clinic, hospital, trained nurse or EMT in the event of illness or injury that requires immediate attention, as determined by the YMCA staff. In the event the participant as named above is injured or becomes seriously ill and I cannot be reached, I authorize any and all hospitalization, medical, dental and/or surgical treatment advisable by the circumstances. I understand that as a parent/legal guardian, it is my responsibility to provide my own accident and health insurance while participating in all YMCA activities, and the YMCA does not provide any health or accident coverage for its participants. I understand that some activities may require travel outside of the city/county limits, State of Washington, and/ or across international borders and will be notified by a permission slip prior to said event(s). I understand that this completed health form will be kept on file until my teen graduates or is no longer involved in any YMCA Teen Leadership Development program and may be photocopied for trips or Teen Leadership programs taking place in other YMCA of Pierce and Kitsap Counties branches. I acknowledge that both sides of this form are correct and complete and the person herein described has permission to engage in any/all registered Teen Leadership Development programs. I grant my permission for photographs/videos which include my teen in YMCA records, program projects, marketing and public relations to be used in media releases for any future promotional purposes. Parent/Guardian Signature Please print name Date

5 YMCA OF PIERCE and KITSAP COUNTIES MEMBER/CHILDREN RELEASE and WAIVER of LIABILITY and INDEMNITY AGREEMENT I am aware that participation in YMCA programs and use of YMCA facilities may involve certain hazards associated with equipment, physical exertion, games, sports, and other programs/activities offered by the YMCA. In consideration of, and as part payment for, the right to use YMCA facilities and participate in YMCA programs, I hold harmless, waive, and release the YMCA ( YMCA includes its employees, volunteers, directors, officers, and agents) for damages of any type, including permanent physical injuries or death, arising out of the ordinary negligence of the YMCA and also for damages of any type arising out of my own negligence, in whole or in part. By participating in the YMCA Nationwide Membership program, I agree to release the National Council of Young Men s Christian Associations of the United States of America, and its independent and autonomous member associations in the United States and Puerto Rico, from claims of negligence for bodily injury or death in connection with the use of YMCA facilities, and from any liability for other claims, including loss of property, to the fullest extent of the law. I assume all risk of injuries and damages associated with my participation in YMCA programs and the use of YMCA facilities including, but not limited to, falls, slips (whether occurring while in the building, offsite as a part of a program, or anywhere else on the YMCA facilities or property, including adjacent sidewalks, access, and parking areas), contact with other participants, sudden and unforeseen malfunctioning of any equipment, instruction, training, supervision, massage, therapy, classes, or dietary recommendations, the effects of the weather and/or temperature indoor or outdoor, and all other such risks being known and appreciated by me. This release includes foregoing any claim I may have for ordinary negligence arising out of my children s use of YMCA facilities or participation in YMCA programs. I understand that it is my responsibility to obtain a physician s release statement if my child has any physical or mental condition that may impair his or her ability to engage in any of the YMCA s programs or activities. I fully understand and agree I am waiving all claims I may have against the YMCA arising out of the ordinary negligent acts by the YMCA, and I agree I will not bring a lawsuit against the YMCA arising out of its ordinary negligence. If any portion of this Release is held invalid, I agree the remainder shall continue to be enforceable. Date: Signature: Printed Name: Criminal History. The Y conducts regular sex offender screenings on all members, participants, and guests. If a sex offender match occurs, the Y reserves the right to cancel membership, end program participation, and remove visitation access. Applicant acknowledges it is the policy of the Y to deny membership to any individual register as a sex offender regardless of offender level or time of conviction.

6 YMCA OF PIERCE AND KITSAP COUNTIES Teen Leadership Programs-Code of Conduct This document will be kept on file until your teen graduates or is no longer participating in program. The Y Teen Leadership Development Programs provide opportunities for all teens to get involved in programs that help build a sense of self-worth in a safe environment. Because of the diverse makeup of all our participants, volunteers and staff, their backgrounds, experiences, and family, it is expected that each person will treat each other according to the YMCA core values of Honesty, Respect, Responsibility, and Caring. Participation in any of the Teen Leadership Development programs is a privilege and not a right. Any actions or behaviors that do not uphold our Y core values and/or break our SAD-TV rules will not be tolerated. Those choosing to break any of these expectations during any Y programming may be removed from programs at the discretion of the Teen Leadership Director. The SAD-TV Rules are as follows: Sex includes, but not limited to: any physical sexual behavior between individuals, sexually explicit comments/innuendos, and/or sharing of any sexual images via social media. Alcohol includes, but not limited to: purchasing/bringing, consuming, distributing any alcoholic beverages during a Y event. This also includes arriving intoxicated to any Y event. Drugs includes, but not limited to: purchasing, distribution, or use of any illegal substance or prescription drug not prescribed to the intended user. This also includes arriving under the influence of drugs to any Y event. Tobacco/Vape includes, but not limited to: purchasing, distribution or use of any tobacco product/vape during any Y event. Violence/Malicious Behavior includes, but not limited to: any physical contact that causes injury to others or self, any threat of physical injury to others or self, any intentional bullying, name calling or ostracizing of any participant, volunteer or adult. Code of Conduct Acknowledgment I understand that the ground rules (no alcohol, drugs, tobacco products, sex, violence/malicious behavior) apply to all YMCA events/programs and will not be tolerated. I agree to abide by these rules, or risk the possibility of being sent home at my parent s expense and/or removed from programs. I understand that YMCA Teen Leadership Development programs and Kids Night Out events are a privilege, not a right. My performance in the programs will determine whether or not I am able to participate in future events. I understand that I am responsible for my behavior/language and I will do my best to create a positive experience for all involved. I understand that if I have knowledge of others breaking SAD-TV, that I will do the responsible thing and inform the Teen Leadership Director. I have read and understand the YMCA Teen Leadership Development Code of Conduct and agree to abide by it while participating in programming. I understand that failure to adhere to the Code s minimum standards of conduct my result in my immediate expulsion from YMCA Teen Leadership Development programs. Teen s Printed Name: Teen Signature: Date: Parent Signature: Date:

7 Teen Leadership Development Programs Payment Schedules Please keep this for your reference Pacific Region Conference Cost: $285 $55 deposit September 2018 $115 payment October 2018 $115 payment November 2018 Youth Leadership Development (YLD) Club Cost: $90 $30 deposit October 2018 $30 payment November 2018 $30 payment December 2018 Youth and Government Cost: $445 $75 deposit October 2018 $65 payment November 2018 $65 payment December 2018 $65 payment January 2019 $65 payment February 2019 $55 payment March 2019 Youth Leadership Development (YLD) Conference Cost: $320 $80 deposit March 2019 $80 payment early April 2019 $80 payment late April 2019 $80 payment May 2019 $55 payment April 2019 Summer of Service Cost: $700 $100 deposit December 2018 $100 payment January 2019 $100 payment February 2019 $100 payment March 2019 $100 payment April 2019 $100 payment May 2019 $100 payment June 2019 FINANCIAL ASSISTANCE The YMCA welcomes all who wish to participate and raises funds through our Annual Campaign to help make this possible. Financial Assistance is provided to individuals, teens and families on a need basis and allows access to all programs and activities at the YMCA. If we can serve you or your family in this way, please complete a Financial Assistance Application available in the packet, online at or any YMCA branch and return to Don Brevik.