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* 1. First Name (Exactly as you wish it to appear in all printed materials such as nametag and billbook)

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* 2. Last Name

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* 3. Your School

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* 4. Correct Pronouns (These will be displayed on your nametag)

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* 5. Your Current Grade

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* 6. How many years previously have you participated in Youth And Government, not including this year?

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* 7. Conference Role You would like (Select all that apply)

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* 8. Street Address

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* 9. City

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* 10. Zip Code

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* 11. Your Email.  Please make sure it is spelled correctly, as this will be the way you receive communication about the program.  Please do not use a school based email address, as most have strong filters and often filter out our emails.

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* 12. Cell Phone Number

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* 13. Home Phone Number

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* 14. Parent/Guardian First Name

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* 15. Parent/Guardian Last Name

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* 16. Parent/Guardian E-Mail

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* 17. Parent/Guardian Cell Phone Number

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* 18. Parent/Guardian Work or Home Phone Number

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* 19. Emergency Contact First Name

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* 20. Emergency Contact Last Name

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* 21. Emergency Contact Relation to Student

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* 22. Emergency Contact Best Phone Number

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* 23. Please list any allergies you have (Dietary/Medicinal/Environmental/etc...)

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* 24. Please indicate if a specific meal type is requested, select any that apply.

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* 25. Other Dietary Requests or Restrictions

For my participation in activities to be conducted by the Alliance of Connecticut YMCAs, I hereby give my permission and consent, now and for all time, to the Alliance of Connecticut YMCAs and collaborating third parties 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 within said activities, for publication, display, sale or exhibition thereof in promotions, advertising, education 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 during said activities, I authorize, according to this Release, shall belong to YMCA of the USA and collaborating third parties. 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 within said activities;

Any video film, footage, sound track recordings and photo reproductions of me and/or my narrative account of my experience within said activities will not be subject to any obligation of confidentiality and may be shared with and used by YMCA of the USA and collaborating third parties;

YMCA of the USA and collaborating third parties collaborating 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; and

YMCA of the USA and collaborating third parties 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 for any purpose without compensation to me.

I agree that my consent and this release are irrevocable. I hereby release and discharge YMCA of the USA and collaborating third parties from any and all claims in connection with the uses and reproductions, any video film, footage, sound track recordings and photo reproductions of me and/or my narrative account of my experience as described herein.

PARENT’S AUTHORIZATION-I support my daughter/son/child in her/his/their participation in the YMCA Youth and Government Program. I hereby give permission to the physician selected by the ALLIANCE OF Connecticut YMCAs representative to order X-rays, routine tests and treatment for the health of my child. In the event that I cannot be reached in an emergency, I hereby give permission to the attending physician to hospitalize, secure proper treatment for, and to order injection and/or anesthesia and/or surgery for my child as named above on this form. I understand that my insurance will cover this expense, or I will assume responsibility for medical expenses resulting from illness and/or injury.

Code of Conduct:

Each participant must abide by the program Code of Conduct explained below during the conference weekend.

1. BASIC PHILOSOPHY OF RESPONSIBLE CONDUCT: Essential to the Youth and Government program is the concern and respect for the rights of every individual. Being responsible for your own behavior and attitude at all times is an essential element of self-government benefiting not only ourselves, but fellow delegates and the Connecticut YMCA Youth and Government Program. All facilities placed at the disposal of the Youth and Government program are to be given the greatest care and attention. It is a PRIVILEGE to use them; treat them with respect.

2. GENERAL RULES: Infractions of the following general rules shall result in expulsion from the YMCA Youth and Government program functions and conferences. In addition local law enforcement agencies may be contacted and the participant/advisor/staff member turned over to them:

a. Laws of the State, County and City are always observed.

b. State Capitol Chamber rules restrict all beverages, food, gum, including phone limitations that we will follow.

c. Possession or consumption of weapons, alcoholic beverages or non-prescribed drugs are not permitted

d. Any act of vandalism, destruction of property, or misuse of a facility may be a crime and will be treated as such.

e. Attendance and punctuality is mandatory at all work sessions

f. Those who decide to be present when a violation occurs shall, by their own choice, be considered a participant in the violation. In this program there are no “innocent bystanders.”

g. This is a full tobacco free event. There will be no smoking, chewing, use of e-cigarettes etc. in the Government buildings, in the hotel or any other facility where Youth and Government activities take place.

h. Badges shall be worn by individuals whose name is on the badge. BADGE SWITCHING OR SHARING IS STRICTLY PROHIBITED. Participants will wear their assigned badges at all times when they are not in their sleeping rooms, and must be able to produce their badges at all times. Badges are to be worn above the waist and must be visible. Badges are not to be defaced, decorated, or altered in anyway. Only advisors can request replacement badges.

i. Delegates will be expected to dress professionally and respectfully.

j. Delegates are required to be in their hotel for and during sessions. It is assumed that the conduct in the hotel will reflect the principles of self-control as outlined in this Code of Conduct

k. Curfew and quiet hours must be observed with each delegate in her/his own room defined by the official schedule

l. No participant shall be in the room of the opposite gender during the conference.

m. Participants are not permitted to drive vehicles to or from an event sponsored by the statewide program.

n. For the safety of all each delegate’s advisor will check their luggage, carry-on bags, coat pockets prior to departure similar to the security check process at an airport.

o. In the interest of our health high energy or high caffeinated beverages are not allowed such as Jolt or Monster.

p. While a variety of dance styles exist, recognize that this is a YMCA event, not a club or dance party event. Inappropriate dancing is in violation of the code of conduct jeopardizing your participation and Premier District standing.

3. Disciplinary Action: This code of conduct is considered binding on all participants, advisors and staff. Each YMCA and its advisors shall be held accountable for all actions and conduct of their participants. The intent is to hold each participant accountable for his/her own actions

The State Director, and your advisor, Have the authority to interpret the Code of Conduct and administer any disciplinary action deemed necessary.

I have read and understand the Connecticut YMCA Youth and Government 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 Connecticut YMCA Youth and Government program.



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* 26. Parent Signature: I agree, and it is my intent, to sign this record/document by typing my name in answer to this question and by electronically submitting this record/document to Connecticut Youth and Government. I understand that my signing and submitting this record/document in this fashion is the legal equivalent of having placed my handwritten signature on the submitted record/document and this affirmation. I understand and agree that by NYS-G04-001 Page 9 of 44 electronically signing and submitting this record/document in this fashion I am affirming to the truth of the information contained therein and agreeing to all conditions outlined.

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* 27. Student Signature: I agree, and it is my intent, to sign this record/document by typing my name in answer to this question and by electronically submitting this record/document to Connecticut Youth and Government. I understand that my signing and submitting this record/document in this fashion is the legal equivalent of having placed my handwritten signature on the submitted record/document and this affirmation. I understand and agree that by NYS-G04-001 Page 9 of 44 electronically signing and submitting this record/document in this fashion I am affirming to the truth of the information contained therein and that I agree to all the terms and conditions specified and agreeing to all conditions outlined.

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