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YMCA of Central Bay Area
Youth & Government
Model Legislature & Court
Registration Form
DELEGATION:
_____Berkeley
____Diablo Valley
____Mt. Diablo
_____SRV Fuerza Unida
____SRV Valle Lobo
____SRV Vista Diablo
Delegate Information
First Name _____________________
M.I. _____
Last Name________________________________
Address/City/Zip: ____________________________________________________________________________
Primary Phone: _____ - _____ - ________
Secondary Phone: _____ - _____ - ________
Email Address: __________________________________
Gender: _____Male _____Female
Birth date (mm/dd/yyyy): _____ - _____ - _____
School: ___________________________________
Grade: ____9 ____10 ____11 ____12
Years in program: ____1st____2nd ____3rd ____4th
Sweatshirt Size (Adult): ____XS ____S ____M ____L ____XL ____XXL ____XXXL
How did you hear about this program? _______________________________________________________________
Parent/Guardian Information
Parent/Guardian (1)
First Name _____________________ M.I. _______
Relationship to Participant: _____________
Primary Phone: _____ - _____ - ________
Last Name________________________________________
Email Address: ____________________________________________
Secondary Phone: _____ - _____ - ________
Is address same as delegate? _____Yes _____No
If no, Address/City/Zip: __________________________________________________________________________
Parent/Guardian (2)
First Name _____________________ M.I. _______
Relationship to Participant: _____________
Primary Phone: _____ - _____ - ________
Last Name________________________________________
Email Address: ____________________________________________
Secondary Phone: _____ - _____ - ________
Is address same as delegate? _____Yes _____No
If no, Address/City/Zip: __________________________________________________________________________
YMCA of the Central Bay Area 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 acknowledgement 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 CONVENANTS NOT TO SUE the YMCA and all branches
thereof, its directors, officers, employees, and agents (hereinafter referred to as "releasees") 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 therefor on account of injury to
the person or property or resulting in death of the undersigned or such children whether caused bv
the negligence of the releasees 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
releasees 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 releasees 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 releasees
or otherwise while in, about or upon the premises of the YMCA and/or while using the premises or
any facilities or equipment thereon or 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 AND UNDERSTAND THIS DOCUMENT AND RELEASE
Delegate Signature:
Date: ___/___/_____
Parent/Guardian Signature:
Date: ___/___/_____
California YMCA Youth & Government Authorization Form
Delegation Name:
_____________________________________________________________
Participant Information
Participant Name _________________________________________________________________
Address ________________________________________________________________________
City _____________________________________________ Zip Code ______________________
Date of Birth (mm/dd/yyyy) _____ - _____ - _____
Gender ________
Age_____
Grade_____
Medical Insurance Carrier ____________________________ Policy Number __________________
Dental Insurance Carrier ___________________________ Policy Number ___________________
Parent or Guardian Name __________________________________________________________
Primary Phone _____ - _____ - ________
Secondary Phone _____ - _____ - ________
Alternate Parent or Guardian Name __________________________________________________
Primary Phone _____ - _____ - ________
Secondary Phone _____ - _____ - ________
Emergency Contact Name __________________________________________________________
Primary Phone _____ - _____ - ________
Secondary Phone _____ - _____ - ________
MEDICAL INFORMATION
Known Allergies:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Medicines currently taking:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Code Of Conduct Agreeance
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 home
from the conference or YMCA function. This transport shall be done at my expense.
Anonymous Data Collection Release
California YMCA Youth & Government continually strives to improve the program experience for
participants. As part of that process we work with other YMCA organizations as well as outside
researchers to design and implement surveys to learn about experiences and growth during Youth &
Government as well as standard background information. The information collected is held in confidence
by California Youth & Government and the researchers have no ability to identify any individual
participant. Identifying information will never be released to anyone outside Youth & Government. During
the course of our study we hope to conduct interviews with individual participants. Before that is done, the
student and the parent will be asked to sign an additional consent form. I have read and agree to these
conditions.
Media Release
Permission is granted for photographs, DVD, video, or audio recording of my child that are taken during
his/her participation in the Youth & Government program, in any format including electronic media, to be
used by the program for any purpose, including publicity. The participant and his/her parents hereby
waive and forever relinquish any rights to such images, waive the right to prior notice of such use, and
acknowledge the right for Y&G to use such images without compensation.
Medical Release
Multijurisdictional authorization and release for medical and dental treatment the undersigned, as the
authorized parent or parents or legal guardian of the above named person, I hereby authorizes California
YMCA Youth & Government and its authorized director and/or leaders (collectively the YMCA) or an
authorized representative of the YMCA Youth & Government Program to act as guardian for the above
named individual. This guardianship grants them authority to consent to any medical, dental, surgical or
mental health diagnosis or treatments, and hospital care to be rendered to the individual under general or
special supervision and upon advice of a health care provider licensed under the laws of the state or any
other jurisdiction in which medical care is sought. For the purpose of medical care or dental care obtained
in the State of California, this authorization is given pursuant to the provisions of section 25.8 of the
California Family Code, as amended. It is understood that if time and circumstances reasonably permit,
the YMCA will endeavor, but is not required, to communicate with the undersigned prior to the rendering
of medical care or dental care for which consent is given pursuant to this authorization. The undersigned
understands and agrees that the YMCA shall not be legally or financially liable for any claim arising from
the medical or the dental care provided pursuant to this authorization. The undersigned hereby agrees to
indemnify and to hold the YMCA harmless from any claim made by or on behalf of said individual arising
out of any medical care or dental care provided pursuant to this authorization. This authorization is given
to the YMCA for use in conjunction with any event operated by the YMCA including transportation to/from
the event and shall be valid until revoked in writing by the undersigned. I hereby indicate by the
signature below that I am the authorized parent or legal guardian for the above minor.
Signature of Agreeance
I, the undersigned, have read, understand and agree to the statements written on page one
and two of this document.
Participant Signature _____________________________________ Date ____/____/_______
Parent/Guardian Signature ________________________________ Date ____/____/_______
Printed Name ________________________________________________________________
YMCA of Central Bay Area
Youth & Government
Model Legislature & Court
Payment Form
The payment schedule for the 2014-2015 Model Legislature & Court program is as follows:
PAYMENT
EARLY BIRD PAYMENT PLAN (July 1- August 31, 2014)
AMOUNT
DRAFT/DUE DATE
1
$350.00
Upon returning of registration forms
2
$300.00
October 1, 2014
3
$250.00
November 1, 2014
4
$200.00
December 1, 2014
5
$150.00
January 1, 2015
6
$100.00
February 1, 2015
Total Cost
$1,350.00
PAYMENT
PAYMENT PLAN (Starting September 1, 2014)
AMOUNT
DRAFT/DUE DATE
1
$350.00
2
$350.00
Upon returning of registration forms
November 1, 2014
3
$250.00
December 1, 2014
4
$250.00
January 1, 2015
5
$150.00
February 1, 2015
Total Cost
$1,350.00
Preferred payment for this program is by credit card or bank draft, but personal check or money order will
be accepted. The first payment, in full, must be attached when returning the completed registration form
prior to October 1, 2014. You can mail all complete and signed forms and first payment to: YMCA PG&E
Teen Center Attn: Richard Chapin 2111 Martin Luther King Jr. Way, Berkeley, CA 94704.
Financial Assistance – File period is August 19 – September 19, 2014
Assistance is available on a first come first serve basis. To qualify for assistance, applicants must attend
all three Model Legislature and Court conferences and attach a non-refundable payment for $50.00 upon
waiting for approval. Failure to do so will result in loss of assistance. All are welcomed to apply. Please
download the form on our website at http://ymca-cba.org/locations/ymca-pge-teen-center/youth-andgovernment . If you file after the closing, assistance may not be available or very limited. Please read and
complete the entire form. Incomplete forms will not be considered. If approved for assistance, a new
payment agreement will be sent to candidates reflecting the new monthly fees.
Fundraising
Throughout the Model Legislature & Court year, delegations engage in several fundraising opportunities.
We encourage all delegates to participate whether they are on financial assistance or not. All monies
earned through fundraising will credited to the most recent payment due. For more information on
fundraisers, please contact the delegation lead advisor.
Annual Campaign Fundraiser
Contributions to the YMCA of the Central Bay Area’s Annual Campaign help fund Youth & Government
programs for teens and enable us to provide financial assistance to those participants who could otherwise
not afford to participate. If you would like to learn more or join the campaign team, please contact Mia
Georgiu at (510) 486-8408 or [email protected]. The YMCA of the Central Bay Area is a nonprofit
501(c)3 organization. Our tax id# is 94-1156635. Contributions are tax deductible to the full extent of the
law.
If you have question on payment, financial assistance, or would like to arrange an alternate payment
schedule, please contact Richard Chapin, Youth & Government Program Coordinator, at (510) 542-2129 or
[email protected].
Payment Information
___ I am awaiting approval for financial assistance. I have attached the non-refundable payment of
$50.00 with this registration form. CK#____________ (made payable to the “YMCA of Central Bay
Area)
___ I would like to make my payments using a personal check. I have attached the first payment or full
amount with this registration form. CK#____________ (made payable to the “YMCA of Central Bay
Area)
____ Please charge the first payment, then draft my credit card or bank account (enter information below)
per the above draft schedule as payment for the program fees.
____ I would like to pay in full. Please charge the credit card below for the full fee amount of $1350.00.
___ I would like to make a contribution to the Annual Campaign to help those Youth & Government
participants who could otherwise not afford to participate. Please charge $__________ to my credit card
or see attached CK#____________ (made payable to the “YMCA of Central Bay Area)
Charges will appear on your bill as YMCA of the Central Bay Area. Please make sure to provide all
payment details. All information will be kept confidential and placed in a secured location.
Credit Card or Bank Draft Authorization
Credit Card
Bank Account Draft
Name on Account:
Name on Account:
_________________________________________
________________________________________
Card Type: ____MasterCard
Account Type:
____Visa
____Amex
____Savings
____Checking
Account Number:
Routing Number:
_________________________________________
_________________________________________
Expiration Date:
__________________
Account Number:
_________________________________________
Agreement – PLEASE INITIAL
_____ I authorize a Credit Card or Bank Draft per the above schedule beginning in September or October 2014 and
ending in February 2015. The draft will occur monthly until the program is expired or contract is terminated in
writing. If a cancellation occurs before a draft/due date, all future drafts/payments will be cancelled.
Once a payment is made and past the draft/due date, there will be no refunds.
_____ Payments not honored by the bank for any reason will incur a $25.00 return payment fee.
_____ Two or more returned drafts or checks may require payment in full for the program or result in termination from
the program.
I HAVE CAREFULLY READ THE ABOVE DOCUMENT AND AGREE TO ABIDE BY ALL OF ITS TERMS.
X Parent/Guardian Signature: __________________________
Date:
/
/
YMCA of the Central Bay Area
Youth & Government
Model Legislature & Court
Code of Conduct Addendum
Model Legislature & Court delegates and advisors of the YMCA of the Central Bay Area are expected to
adhere to the highest standard of behavior. The following additions to the Code of Conduct are
expectations above and beyond the California YMCA Youth & Government Code of Conduct:
1. The Model Legislature & Court program is a participatory activity. Delegates are expected to
attend every scheduled meeting at every conference, and participate locally and at the statewide
level in all activities. This includes voting, bill development, and helping the delegation reach its
community service requirement, which will be a 100% participation activity by all delegates.
2. Attendance is critical to deliver information and ensure informed participation. Delegates that drop
below 80% attendance to delegation events are subject to expulsion from the program. This
program does require a commitment. The last meeting before each conference is mandatory.
3. Intimate behavior is hereby defined as “kissing and beyond.”
4. Attendance at Training & Elections Conference II is Mandatory. If you do not attend this
conference, you will be dropped from the program with no refund of fees paid to date.
5. Delegates and Advisors are expected to show mutual respect for other participants, staff, facilities,
property, and each other regardless of their location or delegation. They will also demonstrate the
four core values of Caring, Honesty, Respect, and Responsibility at all Model Legislature & Court
activities.
6. Payments of fees are due according to the Payment Schedule form or a schedule that is agreed
upon by the parent/guardian and the YMCA staff. We do not give refunds for program fees past a
payment date. Please be sure you can commit to this program before you register.
Expulsion and removal from the program requires immediate transportation of a delegate from the
conference or YMCA event. This is the responsibility of the parent/guardian and:
1. It will be immediate (24 hours a day) commencing with notification from my child, YMCA of the
Central Bay Area staff, and/or California YMCA Youth & Government staff of a violation of the Code
of Conduct.
2. It will be at my sole expense, time, and responsibility. Parents/Guardians must pick up their
delegates.
3. Parents are responsible for the entire cost of any repairs or replacements due to vandalism caused
by their child.
4. Delegates expelled from the Model Legislature & Court program are not eligible for refunds or
credits of any kind.
I have read and understand the California YMCA Youth & Government Code of Conduct, as well as the
YMCA of the Central Bay Area Code of Conduct Addendum, and I agree to all sections. I understand that
failing to adhere to the code’s minimum standard of conduct may result in the immediate expulsion of my
child from the Model Legislature & Court program.
Delegate Signature:
Date: ___/___/_____
Parent/Guardian Signature:
Date: ___/___/_____