Please fill out all information for the student attending.

Question Title

* 1. First Name

Question Title

* 2. Last Name

Question Title

* 3. Your School

Question Title

* 5. Your Home Phone Number.  Please include only the numbers, no hyphens or parentheses.

Question Title

* 6. Your Email

Question Title

* 7. Date of Birth - Please answer in the MM/DD/YYYY format

Question Title

* 8. Gender

Question Title

* 10. Parent or Guardian's name.

Question Title

* 11. Your Parent or Guardian's Email.  

Question Title

* 12. Address ?

Question Title

* 13. City ?

Question Title

* 14. State ?

Question Title

* 15. Zip Code ?

Question Title

* 16. Parent/Guardian First Name ?

Question Title

* 17. Parent/Guardian Last Name ?

Question Title

* 18. Parent/Guardian Email ?

Question Title

* 19. Parent/Guardian Cell Phone Number ?

Question Title

* 20. Parent/Guardian Work or Home Phone Number ?

Question Title

* 21. Emergency Contact First Name ?

Question Title

* 22. Emergency Contact Last Name ?

Question Title

* 23. Emergency Contact Relation to Student ?

Question Title

* 24. Emergency Contact Best Phone Number ?

Question Title

* 25. List any student allergies (Dietary/Medicinal/Environmental/etc...) ?

Question Title

* 26. Meal Requests-Please indicate if a specific meal type is requested

Question Title

* 27. Other Dietary Requests or Restrictions ?

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 their own actions. 

The State Director, and your advisor, Have the authority to interpret the Code of Conduct and administer any disciplinary action deemed necessary.  AT any time, the Conference Staff or Volunteer Advisors may remove a students from any online forum until any concerns have been resolved with the Conference Staff and the District Coordinator(s).

Photo Release: For the protection of the students all conference events will be recorded. By signing this release you state:
For my participation, or that of my child, in activities to be conducted by the Alliance of New York State YMCAs, I hereby give my permission and consent, now and for all time, to the Alliance of New York State 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. I have read and understand the New York State YMCA Youth and Government Code of Conduct and I agree to follow it.
Conference Code of Conduct and Photo Release:

All attendees, speakers, sponsors and volunteers at our conference are required to agree with the following code of conduct. Staff and volunteers will enforce this code throughout the event. We expect cooperation from all participants to help ensure a safe environment for everybody.

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 New York State YMCA Youth and Government Program. 

1.     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.  Badges are to be worn above the waist and must be visible and worn at all times.  Badges are not to be defaced, decorated, or altered in anyway.  Only advisors can request replacement badges.

i.        Delegates w

3.       Digital Expectations:  Equity is a value we strive to adhere to in the YMCA.  We understand that each student has a unique situation and differing levels of access to technology. If you have concerns about access to computer, internet, or other resources in order to participate, please do not let that be a barrier.  Communicate with your District Coordinator or the Conference Director and we will work with you. In conducting an online conference we ask the following things

A.   While you will be able to participate in any aspect of this via calling in by phone, you will be expected to present via videoconference with camera and audio on at all times possible, within reason.

B.   Mute your microphone whenever you’re not speaking, and unmute it before you speak.

C.   Review the materials sent out before the conference on how to use the software and participate fully.




Question Title

* 28. 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 New York State 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.

Question Title

* 29. 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 New York State 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.

T