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youth council registration form
youth council registration form
What pronouns does the participant use?
Participant's date of birth
Date Format: MM slash DD slash YYYY
Relationship to Participant
State / Province / Region
ZIP / Postal Code
Best Phone to reach Parent/Guardian
Participant Ethnicity: Is the participant Hispanic or Latina/Latinx?
Prefer not to answer
Race: Would you describe the participant as (check all that apply, optional)
Native American or Alaska Native
Black or African American
Native Hawaiian or Pacific Islander
Does the participant have any physical condition/disability or allergies we should know about?
If YES, please describe
Emergency Contact #1
Emergency contact #1 Phone
Emergency Contact #2
Emergency contact #2 Phone
What is the participant's method of transportation to/from the YWCA?
Parent/Guardian pick up
Please list names of individuals authorized to pick the participant up from YWCA events
Is there anyone who is NOT authorized to pick the participant up from YWCA events?
If YES, please list
May the participant be filmed or photographed for YWCA youth programming or agency publicity? Photos may be used on our website, social media accounts and/or donor materials. We do NOT use last names.
Let's discuss further
Does the participant quality for free or reduced lunch?
Has your family received TANF (Temporary Assistance for Needy Families) within the past year?
YWCA Olympia is working to understand, assess, and meet the needs of adolescents in our community by way of a program evaluation. This program evaluation will provide us with invaluable information and feedback on how YWCA programs are impacting program participants. All participants will be asked to complete a program evaluation. All evaluations are anonymous and are processed in a confidential manner. Individual questions are optional, and this will be expressed to your child prior to survey completion. Refusal to consent to the program evaluation will in no way affect the services my child may access.
Release & Consent for Program Evaluation
I have READ the Program Evaluation details. I give CONSENT for my child to participate in the evaluation.
Release of Liability: PLEASE READ
On behalf of my minor child (youth named on this registration), I hereby give permission for my child to participate in YWCA Youth Programming. I hereby warrant that both my child and myself are familiar with the risks involved in the activities of YWCA Youth Programming. I acknowledge that my child’s participation in this program is voluntary. I do hereby agree and consent to my child’s participation in YWCA Youth Programming and do assume all risks and hazards that are part of the conduct of the associated activities. I hereby release, absolve, indemnify, and hold harmless YWCA Olympia, their instructors, staff, agents, organizers, and volunteers of any and all liability for damage, injury, or expense of any kind arising out of or connected with my child’s participation in YWCA Youth Programming. I understand that in case of a medical emergency, my own personal medical plan will be used. As a condition of participation in the YWCA youth programming by the youth named in this application, I acknowledge that I have read this consent form, and knowingly, on behalf of my child, assume all the risks associated with participating in any way in YWCA Youth Programming. I hereby release, to the fullest extent permitted by law, the YWCA of Olympia and the affiliates, from any and all actions, claims, demands, or liabilities that I, my assignees, heirs, distributes, guardians, and legal representatives now have or may hereafter have for injury or damage resulting from my child’s participation in these activities irrespective of whether the same is based on breach of warranty, negligence, strict liability, or any other theory or recovery.
Release of Liability Statement
I have READ and AGREE to the Release of Liability.
Parent/Guardian consent to participate in YWCA Youth Council
YES, I give permission for my child to participate in YWCA Youth Council
Your typed (printed) name serves as your signature