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Event: YAC Spring Con - Ferry Beach, ME (Apr. 9-11)
Registration Fee (incl. program, meals and lodging): $50.00 March 31, 2010 Name: Address: Youth email (print legibly) Phone: (c) Parent/guardian Name and phone #s Youth? If yes, what is your age and grade in school? Adult? If yes, check here___________ Congregation you attend: Your adult advisor at this event: Allergies or medical concerns: Dietary preference (circle one): omnivore vegetarian vegan Con leadership will try to respect your preference, but if your diet is limited please bring food supplements for yourself. *****If you are a minor and are driving yourself or driving other minors, your parents need to send a special permission form to the district office. Please call the office at 603-228-8704 or access the form at the district website: http://nned.uua.org/youth.shtml For DRE, minister or youth coordinator: I understand this youth from my congregation is attending the stated event. (signature) LIABILITY RELEASE AND EMERGENCY CARE AUTHORIZATION ATTN: Parents/Guardians PUBLICITY/IMAGE/VOICE PERMISSION Yes_____No_____ Do you give consent for your child’s photo and/or video image to be taken during activities at Northern New England District youth events? Yes_____No_____ Do you give consent for your child’s name and/or image to be posted on the NNED website or district sponsored Facebook sites? MEDICAL EMERGENCY If an injury or other medical condition occurs, I hereby give permission to the NNED staff or volunteers to provide routine first aid and to seek emergency treatment including x-rays or routine tests. I agree to the release of any record necessary for treatment, referral, billing, or insurance purposes. I understand I am financially responsible to the physicians or health care unit. In the event I cannot decide for my child, I give permission to the physician selected by the staff or volunteers to secure and administer treatement for my child, including hospitalization. Parent or guardian signature:_____________________________________________________________ Date: __________________ Insurance Company and Policy #__________________________________ ____________________________________________________________________________________ ASSUMPTION OF RISK AND RELEASE OF LIABILITY I give permission for my child__________________________________________ to participate in NNED youth events. I understand that NNED activities/events may involve certain risks of physical activity and possible injury and that NNED will provide each participant with reasonable care, but that NNED cannot guarantee that my child will remain free of injury. In addition, some NNED events including, but not limited to: winter sports, water activities and other sporting activities have a higher degree of risk. I nonetheless wish to have my child participate in NNED events and ASSUME THE RISK of participation. I agree to release from liability, indemnify and hold harmless the NNED, the Board of Directors, and their officers, employees, and agents from any Registration Deadline: Wednesday,
and all claim and/or cause of action arising out of and related to any injury, loss, penalties, damage, settlement, costs of other expenses or liabilities that occur as a result of my child’s participation in the NNED programs. Parent/guardian signature:_______________________________________________________________ Date:________________ Continue on page 2 COMMUNITY COVENANT FOR YOUTH AND ADULTS I understand each youth event’s community strives to be inclusive, healthy, safe and spirit-centered. Realizing that what I do affects many others in this community, district and our Unitarian Universalist faith I promise to observe the following. • Model self-care by respecting myself, recognizing my physical (sleep!), emotional and psychological needs, and seek appropriate youth or adults with whom to process feelings and concerns. • Refrain from holding, using or distributing illegal substances or weapons • Use appropriate, non-violent and respectful language and behavior • Respect others, physical premises and others’ personal property • Refrain from sexual intercourse of any kind and refrain from any sexual behavior which diminishes inclusive community • Abide by sleeping arrangements (one blanket/bag; one person) I understand that failure to follow these guidelines could include my removal from the event at my parents or my expense and could jeopardize the continuation of youth events/cons. I also agree not to leave the set boundaries of the event without permission or, if an adult, without notification of con coordinators. Youth and/or Adult Advisor signature_________________________________________________________________________ FOR ADULT ADVISORS You will need to establish a relationship with the DRE or minister or youth coordinator in your congregation and ask them to read and sign below. I recognize this adult will be sponsoring youth from my congregation. If he/she has not gone through the district’s screening process I will ask him/her to do so and help them initiate that process at least two weeks before the youth events. Signature of DRE, minister or youth coordinator: ________________________________________________________________ I will be driving and/or sponsoring the following youth from my congregation. (If you are bringing a youth from another congregation, please list here and confirm with his/her DRE and parents that you are assuming responsibility for her/him.) 1_________________________________________________ 2. ________________________________________________ 3. ________________________________________________ 3. ________________________________________________ 4. ________________________________________________ 5. ________________________________________________ 6. ________________________________________________ 7. _________________________________________________ EXPECTATIONS OF ADULTS **Have a good understanding of UUism **Be 25 years or older **If driving youth, have a valid license and insurance **Understand lines of accountability with event leadership and district **Agree to monitor overnight environment by taking two hour awake shifts when necessary **Understand and follow the safety policy of the district and hosting church **Be available to youth while observing appropriate and healthy boundaries **Attend meetings or orientations at youth events/cons and participate in activities **Complete Code of Ethics form necessary to initiate the NNED adult screening process (separate document) and submit to NNED office (address below) not later than Friday, March 26. EVERYONE BRING: Change of clothing and clothing for the weather Toiletries Snacks to share, games to share Musical instruments and/or items for coffee house or dance Sleeping bag, ground mat, pillow Positive attitude! Food Reminder: Please eat dinner before you arrive on Friday night. Meals provided will be: 3 meals on Saturday, breakfast and light lunch on Sunday.
Please RETURN THIS FORM WITH ALL SIGNATURES AND PAYMENT OF $50.00 by Wednesday, March 31, 2010 to: NNED, 10 Ferry St. #318, Concord, NH 03301 or Fax to 603-226-3011. (Please make checks payable to NNED, memo line: YAC Spring Con 2010.) For additional registration information, please contact the NNED office at (603) 228-8704 or via email at email@example.com. For program information, please contact Marsha Lawson, YAC Adult Co-chair, at (207) 233-8714.
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