HELPING TEENS THRIVE Youth & Government CENTRAL YMCA
LEARN MORE WHAT IS YOUTH & GOVERNMENT? Learn first-hand how our state government works not by watching, but by doing! Each September for six months, more than 3,500 high school students throughout California come together in YMCA Youth & Government, a program that develops teens, called Delegates, to learn the values of democracy and to be leaders in the democratic process. Through delegation meetings, exciting weekend conferences, and the 70 th Model Legislature & Court, you can simulate how issues are discussed and how decisions are made in our state to create stronger, healthier, more connected communities. Delegation Meetings During weekly meetings at the Y, you ll discuss current issues in the state and gain hands-on experience in how the government works. You ll work with other Delegates to write a bill, prepare briefs, select governmental positions to role-play, and run for elected offices. Your ultimate goal to take over the State Capitol in Sacramento for one week, where you ll debate the bill at the Youth Assembly and Senate of the California YMCA Model Legislature & Court. Two Conferences Before your trip to Sacramento, you ll prepare and train for your debate, as you join other Delegates from throughout the state at two relaxed and fun weekend conferences in Fresno. You ll conduct committee sessions and model legislative sessions. If you re elected the Youth Governor of California, you ll even preside over the entire conference. 70 th Model Legislature & Court All your work and fun as a Delegate peaks when you convene at the State Capitol. You ll present and debate your bill and work with your friends to implement solutions through the legislative and judicial processes. Join YMCA Youth & Government and make thousands of new friends from all over California! Earn community service hours for high school credit. Learn about the government in a stimulating environment full of moments for fun and socializing during elections, dances and talent shows. Come see what makes YMCA Youth & Government an extraordinary experience!
FEE & PAYMENT INFORMATION FINANCIAL ASSISTANCE Financial assistance may be available, thanks to the generosity of our community donors. Pick up an application at our YMCA or download one at ymcasv.org/central. All applications are handled confidentially. COST PER PERSON Facility Member: $1500 Program Member: $1500 An additional $35 Program Membership Fee is required if you are not a current facility member. Includes transportation, accommodations, conference fees, most meals, sweatshirts, a year-end party, and staff expenses. Does not include all meals in Sacramento or breakfast and lunch while traveling to and from conferences (average $100). PAYMENT INFORMATION We accept personal checks made payable to the YMCA, cash, and MasterCard/Visa. Payments can be made at weekly meetings or at our Membership Services desk. Discover Card is accept for full payment only. IMPORTANT PROGRAM DATES November 10-12, 2017 Training and Elections I Fresno Conference fees include transportation, meals, lodging, program materials, and adult advisor supervision. January 13-15, 2018 Training and Elections II Fresno Conference fees include transportation, meals, lodging, program materials, and adult advisor supervision. February 14-20, 2018 70 th Model Legislature & Court Event site: State Capitol and Sacramento Convention Center Lodging: Hyatt or Sheraton Hotel, Sacramento Event fees include transportation, lodging, the Governor s Banquet, a delegation dinner, program materials, and advisor supervision. REFUND POLICY If your teen stops attending the program at any time, you will be responsible only for the non-refundable direct costs incurred.
PAYMENT OPTIONS CHOOSE 1 of 2 PAYMENT OPTIONS 1. Enclosed is my check or credit information to pay in full: q Facility Members $1500.00 q Program Members $1500.00 q Program Membership Fee $35.00 OR 2. Automatic draft (by credit card or debit card): q Facility Members - 4 monthly payments of $375.00* q Program Members - First payment $410.00* (first payment includes Program Membership Fee) *First Payment: September 3 3 following monthly payments of $375.00 q Facility Members - 6 monthly payments of $250.00* q Program Members - First payment $285.00* (first payment includes Program Membership Fee) *First Payment: September 3 5 following monthly payments of $250.00 Name on account: Card type: Visa MasterCard **Discover **Discover ONLY accepted for full payment Account #: Exp. Date: I (we) herby authorize the Central 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. *If using a checking account, a voided check is required. Parent Signature: Child's Name: To register: Mail this completed form to Central YMCA or return it in person.
REGISTRATION FORM Complete and return this registration form (one per youth) and a Health and Waiver/Release Form to Central YMCA by mail or in person. If paying by check, include your payment, payable to Central YMCA, with your registration form. If paying by credit card or cash, bring your payment with you when you register in person. (One payment per family) Participant s Full Name Birthdate / / Age Sex: M F Email Address Phone Number Address City Zip School Grade Adult T-Shirt Size: XS S M L XL XXL My son/daughter has permission to attend all Youth & Government functions: Meetings: Every Monday through March 2, 2018, 7:00-8:30 pm Fundraising events decided upon by the delegation Training and Elections I: Friday, November 10 - Sunday, November 12, 2017 Fresno Training and Elections II: Saturday, January 13 - Monday, January 15, 2018 Fresno 70 th Model Legislature & Court: Wednesday evening, February 14 Monday, February 20, 2018 Sacramento I have read the fee and payment information and will adhere to deadlines. I certify that my son/daughter is in good health and can participate in all normal activities of the group, and I have filled out the health and waiver/ release form. Parent/Guardian Signature Date Parent/Guardian Name Note: The parent or legal guardian of each participant must fill out this form and the health history form. A YMCA Program Director or its designee will have a photocopy of this form and the health history form at all times during all Youth and Government events and activities, in the event of an emergency.
CENTRAL YMCA California YMCA Youth & Government Delegate Emergency Information Form DELEGATE INFORMATION First Name: Last Name: Address: City: Zip: Cell Phone: Vegetarian: Yes No Date of Birth: Sex: M F Email: School: Grade: 9 10 11 12 Previous Participation: T&EI T&EII Sac Spring PARENT/GUARDIAN INFORMATION First Name: Last Name: Address: City: Zip: Daytime Phone: Evening Phone: E-mail: First Name: Last Name: Address: City: Zip: Daytime Phone: Evening Phone: E-mail: EMERGENCY INFORMATION Emergency Contact Name: Relationship: Doctor's Name and Group: Insurance Policy Group, Name and Phone: Phone: Phone: Dentist's Name and Group: Insurance Policy Group, Name and Phone: Phone: List current prescription medication (separate medication release form required): Describe any allergies, physical restrictions or special considerations: If there are no restrictions, check here:
YMCA OF SILICON VALLEY Release and Waiver of Liability and Indemnity Agreement IN CONSIDERATION of being permitted to utilize the facilities, services and programs of the YMCA (or for my children to so participate) for any purpose, including, but not limited to observation or use of facilities or equipment, or participation in any off-site program affiliated with the YMCA, the undersigned, for himself or herself and such participating children and any personal representatives, heirs, and next of kin, hereby acknowledges, agrees and represents that he or she has, or immediately upon entering or participating will, inspect and carefully consider such premises and facilities or the affiliated program. It is further warranted that such entry into the YMCA for observation or use of any facilities or equipment or participation in such affiliated program constitutes an acknowledgment that such premises and all facilities and equipment thereon and such affiliated program have been inspected and carefully considered and that the undersigned finds and accepts same as being safe and reasonably suited for the purpose of such observation, use or participation by the undersigned and such children. IN FURTHER CONSIDERATION OF BEING PERMITTED TO ENTER THE YMCA FOR ANY PURPOSE INCLUDING, BUT NOT LIMITED TO OBSERVATION OR USE OF FACILITIES OR EQUIPMENT, OR PARTICIPATION IN ANY OFF-SITE PROGRAM AFFILIATED WITH THE YMCA, THE UNDERSIGNED HEREBY AGREES TO THE FOLLOWING: 1. THE UNDERSIGNED, ON HIS OR HER BEHALF AND BEHALF OF SUCH CHILDREN, HEREBY RELEASES, WAIVES, DISCHARGES AND COVENANTS NOT TO SUE the YMCA, its directors, officers, employees, and agents (hereinafter referred to as releases ) from all liability to the undersigned or such children and all his personal representatives, assigns, heirs, and next of kin for any loss or damage, and any claim or demands therefore on account of injury to the person or property or resulting in death of the undersigned, whether caused by the negligence of the releases or otherwise while the undersigned or such children is in, upon, or about the premises or any facilities or equipment therein or participating in any program affiliated with the YMCA. 2. THE UNDERSIGNED HEREBY AGREES TO INDEMNIFY AND SAVE AND HOLD HARMLESS the releases and each of them from any loss, liability, damage or cost they may incur due to the presence of the undersigned or such children in, upon or about the YMCA premises or in any way observing or using any facilities or equipment of the YMCA or participating in any program affiliated with the YMCA whether caused by the negligence of the releases or otherwise. 3. THE UNDERSIGNED HEREBY ASSUMES FULL RESPONSIBILITY FOR AND RISK OF BODILY INJURY, DEATH OR PROPERTY DAMAGE to the undersigned or such children due to negligence of releases or in, about or upon the premises of the YMCA and/or while using the premises or any facilities or equipment thereon or otherwise while participating in any program affiliated with the YMCA. THE UNDERSIGNED further expressly agrees that the foregoing RELEASE, WAIVER AND INDEMNITY AGREEMENT is intended to be as broad and inclusive as is permitted by the law of the State of California and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. THE UNDERSIGNED HAS READ AND VOLUNTARILY SIGNS THE RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT, and further agrees that no oral representations, statements or inducement apart from the foregoing written agreement have been made. I HAVE READ THIS RELEASE. Print Name of Applicant/Parent Print Name of Child in Program Signature of Applicant/Parent Date Print Name of Child in Program Print Name of Applicant/Parent Print Name of Child in Program Signature of Applicant/Parent Date Print Name of Child in Program
CENTRAL YMCA California YMCA Youth & Government Code of Conduct 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 Date 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 Date
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 Date 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 Date