2016-2017 WUSYG Registration Form
**Use/Purpose of this Form: This form is mandatory for youth participants in all onsite and offsite WUSYG programming for 2016/2017. Contact information may be recorded by WUS administrators. All other information will only be seen and used by the Director of Youth Ministries and the Assistant DYM. Youth and parent emails will be automatically added to the WUSYG newsletter listserv. Both youth and parents are strongly encouraged to read the newsletter but can easily unsubscribe at any time.

**Note on Fees/Costs: There is no fee to register, though youth may be asked to bring money to offset/cover the costs of certain offsite activities/excursions. Please notify Sam, the DYM, if your family is experiencing financial difficulties to a degree that prohibits payment for any WUSYG activity and we will find a way to cover the costs.

Youth's Information
Youth's full/legal name
Your answer
Nickname (if applicable)
Your answer
Date of Birth
MM
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DD
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YYYY
Grade
Youth's Cell Phone Number
Your answer
Youth's Email
Your answer
Youth identifies as
Home Address
Your answer
Home Phone Number
Your answer
Parent/Guardian Information
1st Parent/Guardian's Full Name
Your answer
1st Parent/Guardian's Phone (Work or Cell)
Your answer
1st Parent/Guardian's Email
Your answer
Is this parent/guardian interested in being contacted about volunteer opportunities with WUSYG?
* If yes, please select what you are interested in doing (not binding!)
(Optional) 2nd Parent/Guardian's Information
2nd Parent/Guardian's Full Name
Your answer
2nd Parent/Guardian's Phone (Work or Cell)
Your answer
2nd Parent/Guardian's Email
Your answer
Is this parent/guardian interested in being contacted about volunteer opportunities with WUSYG?
* If yes, please select what you are interested in doing (not binding!)
WUSYG Medical Consent, Permission & Release Form
Typing your name in the field below represents your official signature indicating that you agree to the following statement: I authorize the employees, representatives and chaperones of the Winchester Unitarian Society to administer prescribed medication and basic first aid and/or transport to medical treatment, should it be necessary, during my child’s attendance and participation in WUSYG programming during the 2016-2017 school year. In case of emergency, I understand that every effort will be made to contact the Emergency Contacts listed below. In the event that a parent/guardian cannot be reached, I hereby give permission to the Primary Physician, listed below, to secure proper treatment for my child named herein. I will cover the costs incurred.
Parent/Guardian Signature:
Your answer
Parent/Guardian Emergency Contact Number(s):
Your answer
Alternate Emergency Contact #1 full name and phone number
Your answer
Alternate Emergency Contact #2 full name and phone number
Your answer
Youth's Primary Physician full name and phone number
Your answer
Health Insurance Company
Your answer
Policy Number
Your answer
Primary Insurance Holder Name
Your answer
Group/Bin No. (If applicable)
Your answer
Additional Health Insurance Info (If applicable)
Your answer
Please describe any special needs or circumstances which may require accommodations, including but not limited to: visual impairments, hardness of hearing, motor disability, chronic illness, mental disorder, triggers/past traumas, learning/social disability, etc. We are committed to providing ministry to all of our teens and will work closely with parents and teens to provide accommodations and support whenever necessary. *Please remember this information is kept confidential and is also extremely helpful for us in order to build our community in love and trust; your candor is encouraged and appreciated. Please also feel free to contact the Director of Youth Ministries, Sam Wilson: sam.wilson@winchesteruu.org to arrange a personal meeting to discuss any specific questions or concerns relating to the needs of the youth.
Your answer
Youth's Allergies: Please list all medications, foods, and other things that your child is allergic to and please explain the tolerance level and/or severity of the reaction if relevant. If none, please write N/A.
Your answer
Youth's Medications
This information will be kept strictly confidential and will only ever be viewed by the DYM and the Assistant DYM. Some information may also be shared with an adult chaperone in the case of an emergency. This information will be brought by staff to all offsite programming, so, for your child’s safety, please consider full disclosure.
Please list all currently prescribed medications and daily dosage total. If none, please write N/A.
Your answer
Over the Counter Medications
WUSYG staff may, on occasion, administer standard over-the-counter medications (ex. Tylenol, Aspirin, Dramamine, calamine lotion, etc.) if deemed appropriate, at the request of the youth.
Please list any over-the-counter medications that you would NOT like us to administer to your child for any reason.
Your answer
Check this box if you would like us to contact you before ever giving your child ANY kind of over-the-counter medication.
Dietary Information
Youth's Dietary Preferences/Restrictions
In signing this medical form, I hereby certify that the above information is correct and that I I consent and give permission for my child’s participation and attendance in WUSYG programming during the 2015-2016 school year. Furthermore, I give permission for the release of medical records to an attending physician in the case of illness during a program. In consideration of my child’s attendance and participation, I hereby, for myself, my heirs, executors, administrators and assigns, waive and release any and all claims for damages I may have against the Winchester Unitarian Society representatives, chaperones, employees, successors and assigns arising out of any and all injuries to my child while participation in this activity/program.
Typing your name below represents your official signature indicating that you agree to the above information:
Your answer
Date:
MM
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DD
/
YYYY
Photo Release
Photos of the group may occasionally be used for printed and electronic materials that promote, affirm and celebrate our youth ministries. Please ONLY select one of the below options if you will NOT allow us to use a photo that includes your child. Check all that apply.
I refuse permission to use my child's photo for:
Is there anything else that we should know about this youth and/or your family?
Your answer
Notes:
This form is required ASAP for all participants in WUSYG, and the medical consent release must be completed prior to the youth’s participation in any overnight programs onsite or any offsite WUSYG programming. Please feel free to email sam.wilson@winchesteruu.org with any questions or to schedule an in-person meeting. Thank you!
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