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youth council registration form
youth council registration form
What pronouns does the participant use?
Participant's date of birth
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
Does the participant have Medicaid?
What is the participants insurance provider?
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?
How did you find out about Youth Council?
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
The health, safety and well-being of community members participating in YWCA Olympia programs is of the utmost importance. 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 do hereby agree and consent to my youth’s participation in YWCA Olympia Youth Programs and do assume all risks and hazards which are part of the conduct of the associated activities. I hereby release, absolve, indemnify, and hold harmless YWCA Olympia, their officers, directors, employees, contracted employees, independent contractors, instructors, agents, organizers, and volunteers of any and all liability for damage, injury, or expense of any kind arising out of or connected with my youth’s participation in YWCA Programs. I understand that in case of a medical emergency, my own personal medical plan will be used. As a condition of my youth’s participation in YWCA Programming, I acknowledge that I have read this consent form, and knowingly, assume all of the risks associated with participating in any way in YWCA Programming. I hereby release, to the fullest extent permitted by law, the YWCA Olympia and their 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