YOUTH & GOVERNMENT YMCA OF THE EAST BAY SRV Valle Lobo Delegation MODEL LEGISLATURE & COURT
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YOUTH & GOVERNMENT YMCA OF THE EAST BAY SRV Valle Lobo Delegation 2018-2019 MODEL LEGISLATURE Program Guide & & COURT Registration Forms
WELCOME TO YOUTH & GOVERNMENT
IMPORTANT DATES IN THE BEGINNING
The YMCA Youth & Government program was
August 2018 established in 1936 in New York by Clement “Pete”
22nd 1st meeting (returners only) Duran, then the Boys Work Secretary for the
29th 1st meeting (new delegates)
Albany YMCA. The program’s motto, “Democracy
must be learned by each generation, “ was taken
September 2018
19th Registration deadline from a quote by Dr. Earle T. Hawkins, the founder
28th Financial Assistance application deadline of the Maryland Youth & Governemnt program.
Encouraged by then Governor Earl Warren, Youth &
October 2018 Government made it’s debute in California in 1948.
1st Payment #1 due
TODAY
Charted as an independent YMCA in 2001, The
Payment #2 due California YMCA Youth & Government is the premier
Mandatory delegation meeting organization that delivers a high-powered civic
Training & Elections Conference I engagement experience serving close to 5,000 middle
Fresno, CA and high school teens annually.
December 2018 Middle School delegates enjoy a great experience on an
1st
Payment #3 due international level solving world issues in Model United
Nations. Where as high school delegtes par-take in a
January 2019 model California creating and debating legislation and
1st Final payment due proposals and arguing court cases.
16th Mandatory delegation meeting
19th to 21st Training & Elections Conference II
Fresno, CA
February 2019 TABLE OF CONTENT
6th Mandatory delegation meeting
14th to 18th 71st Model Legislature & Court Important Dates..................................2
Sacramento, CA
History of Y&G................................... 2
March 2019
6th New officer election, last meeting Adult Involement.................................3
27th Banquet
School Absence...................................3
CONTACT INFORMATION Delegation Meeting Info......................4
Richard Chapin
Youth & Government Coordinator
Conferences.......................................5
510-542-2129
rchapin@ymcacba.org Code of Conduct.................................6
Chelsae Bilte Registration Info................................8
Lead Volunteer Advisor
srvvallelobo@gmail.com
Registration Foms.............................10
Mitchell Rogers
Delegation President
mitch94529@gmail.com
2 MODEL LEGISLATURE & COURT 2018-2019 SRV VALLE LOBO DELEGATION
WELCOME TO YOUTH & GOVERNMENT
Adult Involvement
YOUTH & GOVERNMENT CORE STAFF
The President/CEO of the California YMCA Youth
& Government is employed by a Board of Directors
to administer the policies and the practices of the
programs. Along with a small core staff, Y&G provides
administrative services to local delegations, fundraise
for financial assistance, and plan conference logistics.
PROGRAM STAFF
Each year over 200 volunteer program staff from
across the state serve as program staff. Recruited and
trainined by Youth & Government, these volunteers plan SCHOOL ABSENCE- SB 278 Lowenthal
and execute each of the various program areas, perform During the Model Legislature & Court conference in
logisitc duties, and provide and promote safety and Sacramento, delegates will experience school absence.
wellness to all participants. They include everyone from Mainly Thursday and Friday of that conference.
teachers to lawyers to public service workers.
In 2008, then Governor Arnold Schwarzenegger
signed SB 278 (Lowenthal) into law allowing Youth &
DELEGATION ADVISORS
Government programs to be an excused absence from
Advisors provide the leadership to their own local
school. The full text of the section is below and may be
delegations in preparing them for their paraticipation
found at www.leginfo.ca.gov by searching the education
in the program. They accompany their delegation to
code for section 48205. (a) (7)
all conferences and various events, provide direct
supervision, and seeve as parlimentarians. Each
48205. (a) Notwithstanding Section 48200, a
advisors is trained in youth development and child
pupil shall be excused from school when
abuse prevention. We maintain a ratio of 1 advisor to
the absence is:
10 delegatges.
(7) For justifiable personal; reasons, including, but
limited to, an appreaence in court, attendance at a
funeral service, obervance of a holiday or ceremony
of his or her religion, attendance a religious retreats,
attendance at an employment conference, or attendance
at an educational conference on the legislative or
judicial process offered by a nonprofit organization
when the pupil’s absence is requested in writing by
the parent or gardian and approved by the principal
or a designated representative pursuant to uniform
standards established by the governing board.
The YMCA does their best to inform every school our
delegates attend to receive full cooperation and support
of this program.
YMCA OF THE EAST BAY WWW.SRVVALLELOBO.ORG 3
SRV VALLE LOBO DELEGATION MEETINGS
OUR WEEKLY MEETINGS
The delegation is ran by a delegate-lead team of
officers that meet weekly to plan the evening’s agendas.
Here is a sample of what an agenda looks like:
1. Invocation- Words of wisdom given by the
Chaplain to set the positve tone for the meeting.
2. Family Groups- Delegates are placed into smaller
groups where they develop close relationships,
discuss needs, get information, and ask
questions about the program.
3. Committees- Delegates lead break out groups
to plan service-learning projects, research bill
ideas, create fundraising strategies, etc.
4. Officer/Advisor Time- This is the time when
officers and or advisors deliver important
information and remind delegates of due dates,
MEETING LOCATION deadlines, and other information.
San Ramon Valley High School 5. Benediction- Our Chaplain ends the meetings
501 Danville Blvd with further deep thoughts leaving delegates
Danville, CA 94526 with something to think about after the meeting.
MEETING TIME
6:00pm to7:30 pm
ANNUAL FUNDRAISING CAMPAIGN
MEETING DATES Our Annual Campaign takes please in the fall where
August 22 (Returning delegates only), 29, 2018 we raise money for financial assistance and program
stability. The SRV Valle Lobo delegation has set a goal
September 5, 12, 19, 26, 2018 of $5,000 to help those who can not afford the full
cost of this program.
October 3, 10, 17, 24, 2018
To donate, please contact Richard Chapin at rchapin@
November 7*, 14, 28, 2018 ymcacba.org
December 5, 12, 19, 2018
January 9, 16*, 30, 2019
February 6*, 13, 27, 2019
March 6,13, 20, 27, 2019
*denotes Mandatory Meetings
4 MODEL LEGISLATURE & COURT 2018-2019 SRV VALLE LOBO DELEGATION
STATEWIDE CONFERENCES
TRAINING & ELECTIONS MODEL LEGISLATURE & COURT
CONFERENCES CONFERENCE
The Training & Elections conferences are designed to The Model Legislature & Court conference is the
give delegates the skills and knowledge to prepare final event of the program. Through the five (5)
themselves for their final conference in Sacramento. days, delegatges will emulate various roles of our
They learn soft skills, get information and training state government and court systems to set up a
on the program areas and elect leadership roles. The model California. The weekends also provide fun
weekends also provide fun social activities for delegate social activities for delegate interactions. Detailed
interactions. Detailed information will be provided two information will be provided two (2) weeks prior to the
(2) weeks prior to each conference. conference.
Training & Elections Conference I (T&E I)
November 9-11, 2018 71st Model Legislature & Court
Fresno Convention Center February 14-18, 2019
State Capitol, Sacramento Convention Center, and
Training & Elections Conference II (T&E II) surrounding State buildings
January 19-21, 2019
Fresno Convention Center
HOUSING TRANSPORTATION
Delegations will be housed in hotels in the convention Transportation to and from all conferences are by
center areas. Delegates are assigned four (4) to a room chartered bus. Bus pick up and drop off locations and
to minimize cost. The rooms will either have one king- times vary between conferences. Information will be
size bed or two queen-size beds. We do our best to made available two (2) weeks prior to each conference
assign these rooms equally among the genders. Roll of the delegation web page.
away beds are not always avaiable so we ask those
who may have an air mattress or sleeping pad to bring
them along for comfort of those in single bed rooms.
The amount of single vs. double rooms are not known
until we arrive at each conference. We do our best to
accommodate all special requests.
SAFETY AND WELLNESS
For our safety and wellness, Youth & Government provides trained volunteers known was Safety & Well ness
Advisors (SWA). These individuals provide us services such as security and medical attention. They creaste program
boundaries, provide additional supervision, and handle minor medical needs.
During the evenings, the SWA enlists the help of the delegation advisors to perform duties to monitor delegate
activity. This includes but not limited to floor duties at hotels, cross walk monitors, elevator monitors, culinary
assistance, etc. SWA are housed at every hotel where there are Youth & Government delegations. The more we look
out for each other, the safer everyone will be.
YMCA OF THE EAST BAY WWW.SRVVALLELOBO.ORG 52018-2019 Y&G CODE OF CONDUCT It is essential to California YMCA Youth & Government (Y&G) that each participant enjoys the right to a safe environment. Being responsible for one’s own behavior at all times is a necessary part of self-government. It is critical that all delegates, advisors and program volunteers act responsibly. The Code of Conduct shall be observed by both youth and adult participants. There will be no double standards. By choosing to participate in Y&G’s programs, each participant (and their parent or guardian, should it apply) agrees that they have read, understand, and will follow the Y&G Code of Conduct while attending any Y&G activities. Some delegations may have additional standards but all Y&G participants are held to the Code of Conduct listed below. Each participant is accountable for preserving the reputation and high expectations of their delegation as well as that of California YMCA Youth & Government. All participants share equally in the responsibility to uphold and enforce the Y&G Code of Conduct. It should be the goal of all participants to notify the appropriate advisor or staff when violations are witnessed. Participants who do not remove themselves from situations or groups which constitute violations of this code will be considered a party to the violation. I. GENERAL RULES Violations of General Rules a-j shall result in expulsion from all Youth & Government (Y&G) activities and conferences for the remainder of the program year. In order to ensure the safety of all participants, Y&G reserves the right if deemed necessary to conduct searches of baggage, rooms and persons; including the use of Breathalyzers in accordance with Y&G policy. In addition, Y&G reserves the right to refer appropriate matters concerning illegal conduct by delegates, advisors, and or program volunteers to local law enforcement agencies for criminal prosecution: a. All public and private facilities placed at the disposal of California YMCA Youth & Government are to be given the greatest care and attention by everyone. b. Any act of vandalism, destruction of property, misuse of a facility and or harassment of facility staff member is strictly prohibited. c. Possession and or consumption of illegal drugs is strictly prohibited. Regardless of a medical doctor’s prescription, marijuana or any marijuana related products are still considered illegal drugs and are strictly prohibited. d. Possession and or consumption of alcoholic beverages by persons under the age of 21 is strictly prohibited. e. The consumption of alcohol by advisors and program volunteers is strictly prohibited during the entirety of every conference and/or training. This restriction is lifted only when the conference is over or your job is complete and you have checked out of the event. Advisors and program volunteers should refer to the Volunteer Handbook for additional rules regarding alcohol consumption. f. Weapons of any kind, as well as items that could cause injury to participants or damage to property are strictly prohibited. g. Any violation of local, State or Federal laws are strictly prohibited and the proper authorities will be notified. h. Conduct that endangers the health and safety of oneself or others is prohibited. i. Inappropriate or uninvited physical contact between any Y&G participants, advisors, program volunteers or guests is prohibited. Intimate sexual behavior is inappropriate and not allowed. j. Possession and or the use of any tobacco, nicotine, or vapor products or devices (including e-cigarettes, vape pens) are strictly prohibited.
Violations of General Rules k-t may result in expulsion from California YMCA Youth & Government functions and
conferences:
k. A badge shall only be worn by the participant whose name appears on the badge. Badge switching or sharing is
strictly prohibited. Participants shall wear their assigned badges at all times when they are not in their sleeping
rooms. Badges are to be worn above the waist and must be visible. Badges are not to be defaced, decorated, or
altered in any way. Only advisors may request replacement badges for delegates.
l. Specific rules as set by the individual facilities (i.e., YMCA, State Capitol, Convention Centers, Hotels, California
National Guard facilities, etc.) are to be observed. Any violation of facility rules shall be considered a violation of
this Code of Conduct.
m. Participants shall be present and punctual to all meetings where their involvement is required.
n. Participants shall observe all curfews and be in their own assigned sleeping rooms at the established curfew
times. Participants may not switch rooms without advance confirmation from their delegation lead advisor.
o. Physical, psychological, verbal, nonverbal, written, or cyber bullying is strictly prohibited.
p. In conferences with hotels, no delegate shall be present in the hotel room with a member of the opposite sex
unless an advisor is present in the room; or there are five or more delegates present in the room, two of which are
the same gender (3-2 rule).
q. Y&G does not permit delegates to drive vehicles to or from any of its related conferences. Advisors seeking to
drive during a conference shall obtain clearance through Y&G. In all cases, liability is assumed by the sponsoring
local YMCA or school.
r. All electronic devices (except those used by the Y&G staff and program volunteers) must be turned off during all
sessions, meetings, and hearings in all program areas. Advisors and program volunteers may leave devices on, but
silenced, for emergency contact reasons and must leave the session/area in order to answer a call.
s. Falsification of records threatens the integrity of the program and will be considered a serious breach of
contract. The result will include a range of penalties up to dismissal from the program. Any act of dishonesty or
fraud threatens the integrity of the program and is strictly prohibited.
t. While at MUN Training, no delegate shall be in the barrack of the opposite gender while at Camp Roberts.
II. DRESS RULES FOR OFFICIALLY SCHEDULED SESSIONS
For each program, refer to Dress Code Supplements for specific requirements. California YMCA Youth & Government’s
CEO has the authority to determine both the appropriateness of appearance and attire of participants, advisors and
program volunteers.
III. DISCIPLINARY ACTIONS
a. The Code of Conduct is binding on all delegates, advisors and program volunteers. Each person will be accountable
for his/her actions. In addition, each YMCA or school and its advisors shall be held accountable for the conduct of
their delegation.
b. California YMCA Youth & Government’s CEO has the authority to make accommodations or exceptions with the
Code of Conduct. Any delegation seeking an exception or accommodation must clear it in advance with their local
YMCA Executive Director/CEO or, in school based delegations, School Principal, and must provide a written request
to the Y&G CEO prior to the related conference.
c. California YMCA Youth & Government’s CEO has the authority to interpret the Code of Conduct and administer any
disciplinary action deemed necessary.
d. California YMCA Youth & Government’s CEO has the authority to delegate his/her disciplinary powers to any
person deemed appropriate.
e. All expenses and arrangements related to any disciplinary action or expulsion from the program are the sole
responsibility of the parent or guardian of the delegate. If a parent is unable to assume financial responsibility for
the delegate, then the YMCA or school must assume responsibility.
IV. LOCAL YMCA RULES
Each YMCA or school may outline additional or stricter rules of conduct for its delegation as long as they do not
conflict with or attempt to diminish any standard in the Y&G Code of Conduct. A violation of either the Y&G Code
of Conduct or the local delegation’s rules may subject the offender to termination from the program. Delegation
advisors shall be responsible for enforcing such additional rules of their local YMCA or school.
Changing the world, one leader at a time.
Updated 7/31/2017REGISTRATION INFORMATION
PROGRAM FEE REFUND POLICY
The program fee for 2018-2019 is $1,600. It covers a Refunds must be requested, in writing, seven (7)
variety of expenses such as: days prior to a payment/draft in order for all future
payments to be refunded. However once a payment/
• Conference registration fees draft date has passed, the fee is no longer refundable.
• Conference transportation and lodging Our expenses for the program depend on the payments
• Delegation appearal from our delegates. Same process applys for those who
• Delegation dinner in Sacramento pay for the program in full.
• Program expenditures*
RETURN PAYMENTS
*Direct expenses to cover volunteer Advisor’s registration
fees, transportation, lodging, and indriect administration Payments not honored by the bank for any reason will
expenses. incur a $5 return payment fee. For those on credit
card draft, please make sure the expiration date on
the card has am expiration after 02/2019. It will be
PAYMENT INFORMATION & SCHEDULE the responsibility of the cardholder to inform Richard
Program fees can be paid for by using the following: Chapin of any changes in the card information.
• Bank Draft/EFT
• Credit Card (American Express, MasterCard, or VISA) FINANCIAL ASSISTANCE
Here at the YMCA we do not turn away those from
Personal checks or money orders will not be accepted programs who are unable to afford the full fee. Our
unless it is for the full fee. No exceptions. finanical assistance (FA) program is available on a first
Make checks payable to YMCA of the East Bay come, first serve basis. To qualify, applicants must
attend all required program conferences. Failure to do
Payments can be made for the full amount or by the so will result in loss of assistance. Please make sure
payment schedule below. If a payment is missed, it will that all reqired information is filled out with backing
be added to the next due date. If a participant misses documents stated on the application before you turn it
two (2) payments in a row, they will be considered to in. Imcomplete applications will not be processed. All
be terminated from the program with no refunds, It is are welcomed and encouraged to apply. Funds for our
the responsibllity of the parent/guardian to make sure FA program are raised by the delegates, their family, and
payment is received on time. friends during our Annual Fundraising Campaign. Last
day to apply is September 28, 2018.
Payment Amount Draft/Due Date
1 $400 October 1, 2018
2 $400 November 1, 2018
3 $400 December 1, 2018
4 $400 January 1, 2019
When paying by bank draft or credit card, we will set up
an automatic payment based on the draft date above.
8 MODEL LEGISLATURE & COURT 2018-2019 SRV VALLE LOBO DELEGATIONREGISTRATION INFORMATION
Please follow these steps for a successful registration in to the Youth & Government program
Step
#1
Please read through this guide and note important information on dates, deadlines,
responsibilities and other desescriptions.
Complete all registration forms at the end of this guide.
Step 1. The primary adult in the household should to complete the forms.
#2
2. All forms are formated as a writable PDF for your convience.
3. If you choose to handwrite, please use black or blue ink.
4. Print and sign all signature areas.
5. Return forms on the due date designated by the Lead Advisor or mail to
Richard at the YMCA-PG&E Teen Center. Address is on the back cover
All parts of forms and waivers need to be filled out and agreed upon in order to participate in this
program.
Once your paperwork has been entered in our registration system, the primary adult
Step will receive an email with instructions on how to set up their My Y Account.
#3
My Y Account allows the primary adult to:
• Enter bank draft and credit card information
• Update any change of address, phone, or email
• Pay any outstanding or future balances.
The YMCA can no longer take full credit card/bank draft numbers on paper for the protection of your
information.
Step
#4
The last step is conference registration through California YMCA Youth & Government.
Once the conference event is open in their registration system, all participants will
receive information on how to register. Failure to do so after the closing deadline will
result in removal of the program.
For registration or My Y Account assistance, contact
Richard Chapin at 510-542-2129 or rchapin@ymcacba.org
YMCA OF THE EAST BAY WWW.SRVVALLELOBO.ORG 9YMCA of the East Bay
Youth & Government, Model Legislature & Court
SRV Valle Lobo Delegation 2018-2019
FOR YMCA ADMINISTRATION ONLY:
Date Received: _____________ Date Entered in DAXKO: _____________ Entered by: ______________ Member ID: _______________
Participant Name (1 person per packet)
First: ____________________Last: _____________________________ Gender: ____Male ____Female____Other
Address: _____________________________________________________City: _________________Zip: ________
Primary Phone: _________________Secondary Phone: ________________Email: ____________________________
Birth date (mm/dd/yyyy): ___________________Age: ____School: _____________________________Grade: ____
_____ African American_____ Asian/Pacific Islander_____ Caucasian_____ Hispanic/Latin
_____Middle Eastern_____ Multi-Racial_____Native American_____ Other ___________________
Years in the Model Legislature & Court program: _____ Sweatshirt Size (Adult unisex size): _____
Parent/Guardian (Primary)Main adult contact person living with this delegate
First: ___________________Last: ____________________________ Birth date (mm/dd/yyyy): ________________
Primary Phone: _________________Secondary Phone: ________________Email: ____________________________
Parent/Guardian (Secondary) Alternative adult contact person for this delegate
First: ___________________Last: ____________________________ Birth date (mm/dd/yyyy): ________________
Primary Phone: _________________Secondary Phone: ________________Email: ____________________________
Family Information
Main Language Spoken at Home: ________________ Main Language Spoken by Parents: ________________
Family Income:
Family information collected
_____Under $20,000 _____$50,001 to $60,000 here is used by the YMCA
strictly for data collection to
_____$20,000 to $30,000 _____$60,001 to $70,000
be used for reporting and
_____$30,001 to $40,000 _____$70,001 to $80,000 funding purposes only.
_____$40,001 to $50,000 _____Over $80,000
Total Number of People in Household: _____
Does the participant qualify for free/reduced lunch? _____Yes _____NoYMCA of the East Bay
Youth & Government, Model Legislature & Court
SRV Valle Lobo Delegation 2018-2019
YMCA of the East Bay
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.
Signature of Agreement I have read and understand this document and release
Participant Name (Print): _______________________________________________
Participant Signature: _________________________________________________ Date: ___________________
Printed Name of Parent/Guardian: ________________________________________
Parent/Guardian Signature: _____________________________________________ Date: ___________________YMCA of the East Bay
Youth & Government, Model Legislature & Court
SRV Valle Lobo Delegation 2018-2019
Participant Medical Information for YMCA of the East Bay
First: ________________________Last: ______________________________ Gender: ____Male ____Female____Other
Address: _________________________________________________________City: _________________Zip: ________
Primary Phone: _________________Secondary Phone: __________________Birth date (mm/dd/yyyy): ___________________
Age: ______
Parent/Guardian (Primary)
First: __________________________________Last: ________________________________________
Primary Phone: ____________________Secondary Phone: _____________________
Parent/Guardian (Secondary)
First: __________________________________Last: ________________________________________
Primary Phone: ____________________Secondary Phone: _____________________
Emergency Contact
Name: _____________________________________Primary Phone: _________________Secondary Phone: __________________
Name: _____________________________________Primary Phone: _________________Secondary Phone: __________________
Medical Insurance Carrier: _________________________________ Policy Number: ___________________________
Dental Insurance Carrier: __________________________________ Policy Number: ___________________________
Medical History (check all that apply)
_____ ADD/ADHD _____ Asthma _____ Bleeding/Clotting Disorder _____ Celiac Disease _____ Chicken Pox
_____ Currently under Dr. Care _____ Diabetes_____ Ear Infection _____ German Measles _____ Heart Defect/Disease
_____ Measles _____ Migraines _____ Seizures_____ Sleepwalking _____ Tuberculosis
List Other Medical History Here:YMCA of the East Bay
Youth & Government, Model Legislature & Court
SRV Valle Lobo Delegation 2018-2019
Allergies (check all that apply)
_____ Foods_____ Bee Stings _____ Hay Fever _____ Pollen _____ Penicillin _____ Other Insects Stings
_____ Other Drugs _____Other Allergies
List Specific Food and/or Other Allergies Here:
List Dietary Restrictions Here:
What (if any) medical condition(s) do you have that could affect your experience in this program?
If you are taking any prescription medication, please list them.
List any past serious medical treatment such as operation, injuries or restrictions.
Is your teen currently involved in therapy? _____ Yes _____ No
Please explain:
Does your teen require special accommodations? _____ Yes _____ No
Please explain:
If you are taking any prescription medication, please list them.YMCA of the East Bay
Youth & Government, Model Legislature & Court
SRV Valle Lobo Delegation 2018-2019
Please read the following. Every section must be agreed upon in order to participate in this program.
Medical Release
I hereby authorize YMCA of the East Bay and its authorized director and/or leaders (collectively the YMCA) or an authorized representative of
the Y&G program in conjunction with the local YMCA to act as guardians for the above named individual. The guardianship grants 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
emergency 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. I have read and agree to these conditions.
For parents or guardians with participants under 18, all efforts will be made to contact the minor’s parent or legal guardian prior to the
rendering of medical or dental care. If the emergent nature of the event demands immediate attention, the above listed guardians are
authorized to provide the necessary permission needed for required treatment required. The undersigned understands and agrees that YMCA
of the East Bay and California YMCA Youth & Government shall not legally or financially liable for any claim arising from the medical, dental,
or mental health care provided pursuant to this authorization. I hereby indicate by the signature below that I am the authorized parent or
legal guardian for the above minor.
The undersigned hereby agrees to indemnify and hold YMCA of the East Bay harmless from any claim made by or on behalf of said individual
arising out of any medical, dental, or mental health care provided pursuant to this authorization. This authorization is given to YMCA of the
East Bay for use in conjunction with any event operated by YMCA of the East Bay including transportation to/from the event and shall be valid
until revoked in writing by the undersigned.
Code of Conduct Agreeance
For participants: By signing, I acknowledge that I have read, understand and will follow the California YMCA Youth & Government (Y&G) Code
of Conduct at all conferences or YMCA functions.
For parents/guardians of participants: By signing, I acknowledge that I have read and reviewed the Code of Conduct with my child 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 their immediate transport home from the conference or YMCA function. This transport shall be done at
my expense.
Anonymous Data Collection Release
YMCA of the East Bay (YEB) 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 Y&G,
as well as standard background information. The information collected is held in confidence by YEB and the researchers have no ability to
identify any individual participant. Identifying information will never be released to anyone outside YEB. During the course of our study, we
hope to conduct interviews with individual participants. Before that is done, the participant and their parent or guardian 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 participants that are taken during their participation in the YMCA of
the East Bay (YEB) and California YMCA Youth & Government (Y&G) 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 YEB and Y&G to use such images without compensation. I
have read and agree to these conditions.
Participant Hotel Accommodations
I understand that hotel sleeping accommodations are shared with other participants up to the maximum allowed by fire code as determined
by hotel standards. Delegates seeking reasonable housing accommodations must communicate their request in advance of conferences to
their local YMCA who will work with Y&G housing team. If there are any concerns or questions about housing at conferences, contact the
YMCA of the East Bay.
Program Guide Acknowledgement
I, as the parent/guardian, hereby understand and acknowledge that I have read or in the process of reading the program guide for the Youth
& Government’s Model Legislature & Court program. By signing this form, I acknowledge that I understand the provisions, and agree to abide
by the rules, polices, and standards set forth in the guide. If I need further clarification, I will contact the YMCA.
Signature of Agreement I have read, understand, and agree to the statements above
Participant Name (Print): _______________________________________________
Participant Signature: _________________________________________________ Date: ___________________
Printed Name of Parent/Guardian: ________________________________________
Parent/Guardian Signature: _____________________________________________ Date: ___________________YMCA of the East Bay
Youth & Government, Model Legislature & Court
SRV Valle Lobo Delegation 2018-2019
Payment Form
Participant’s First and Last Name: ___________________________________________________________________
Primary Form of Payment (Personal checks or money orders are NOT accepted unless it’s for the full fee)
Credit Card OR Bank Draft/EFT
Name on Account: ________________________ Name on Account: ___________________________________
Last 4 digits on card: _______________ Last 4 digits of Routing Number: _______________________
Expiration Date: __________ Last 4 digits of Account Number: _______________________
Secondary Form of Payment (Personal checks or money orders are NOT accepted unless it’s for the full fee)
This account will be used when the Primary Form of payment is returned. It will be drafted automatically with a $25 fee.
Credit Card OR Bank Draft/EFT
Name on Account: ________________________ Name on Account: ___________________________________
Last 4 digits on card: _______________ Last 4 digits of Routing Number: _______________________
Expiration Date: __________ Last 4 digits of Account Number: _______________________
Payment Frequency
_____ Fee in Full- $1,600 _____ Payment Schedule (See page 8 of the Program Guide)
Financial Assistance (Optional)
_____ I want to apply for assistance _____ No, thank you
Assistance is on a first come-first serve basis. In order to process, the signed application and backing financial are
required. Application at www.srvvallelobo.org Incomplete applications will not be processed.
Annual Campaign Fundraiser (Optional)
_____ I would like to make a tax-free contribution to the Annual Campaign to help those participants who could
otherwise not afford to participate. Make check payable to YMCA of the East Bay Ck# _________
Agreement- Please initial
_____ Payments not honored by the bank for any reason, (including returned check, NSF, closed account, invalid
expiration date, referral) will incur $15 returned payment fee. This is in addition to any fees charged by the bank. In
the event a payment is returned, we will automatically redraft, using the second form of payment and will include the
$15 return payment fee.
_____ The YMCA has the right to initiate legal action for collection of fees or outstanding balances, and the
undersigned will be responsible for all costs of collection, including court expenses and reasonable attorney’s fees.
I HAVE CAREFULLY READ THE ABOVE AGREEMENT AND AGREE TO ABIDE BY ALL OF ITS TERMS.
Signature: ______________________________________________________ Date: __________________YOUTH & GOVERNMENT
MODEL LEGISLATURE & COURT
SRV Valle Lobo Delegation
YMCA OF THE EAST BAY
YMCA-PG&E Teen Center
2111 Martin Luther King Jr. Way
Berkeley, CA 94704
510-542-2129
www.srvvallelobo.org
www.calymca.orgYou can also read
