Adult Registration for New York State YMCA Youth And Government
First Name *
Your answer
Last Name *
Your answer
Cell Phone Number *
Your answer
Work Phone Number *
Your answer
Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
District *
Club *
Your answer
Allergies/Dietary Restrictions *
Your answer
Gender *
Shirt Size *
E-Mail *
Your answer
Number of Years in Youth And Government *
Your answer
I am a *
If in college, I am a
As an adult volunteer at the conference, you will be assigned to help out with various conference duties. By indicating below your level of interest in any of these we will attempt to distribute these assignments as best we can. Not checking a box means you are fine with whatever we decide.
Very Interested
Interested
No Interest
Assembly Microphone Transportation Specialist
Bus Monitor
Committee Chair Support
Committee Observer
Dance Monitor
Election Assistant
Fun Time Monitor
Hall Monitor
Judicial Program
Logistical/Printing Assistance
Meal Crowd Management
Media
Night Duty
Has your Youth in Government program or school performed a background check on you In the past 12 months? *
Have you ever been convicted of a crime except a minor traffic violation? *
Your answer
In connection with my application to serve as a volunteer with the NY State Youth and Government program, I understand that the YMCA may run a Criminal Background check requesting information regarding criminal history and the sexual offender registry. I hereby authorize, without reservation, any Law Enforcement Agency, Institution, Information Service Bureau, School, Employer, Reference or Insurance Company to furnish the information described in this form. Please confirm your understanding by writing your initials in the box below. *
Your answer
Emergency Contact Info
First Name *
Your answer
Last Name *
Your answer
Cell Phone Number *
Your answer
Work or Home Phone Number *
Your answer
Gender *
Relation to you: *
Your answer
ADVISOR CODE OF ETHICS / EXPECTATIONS
ADVISOR CODE OF ETHICS / EXPECTATIONS
1. Advisors must appear clean, neat, and appropriately attired with business attire.
2. Smoking or use of tobacco products in the presence of teens or parents during program activities is prohibited.
3. Using, possessing, or being under the influence of alcohol or illegal drugs during program activities is prohibited.
4. Advisors shall not abuse teens in any way including:
a. physical abuse - strike, spank, shake, slap;
b. verbal abuse - humiliate, degrade, threaten; and
c. sexual abuse - inappropriate touching or sexual innuendos
5. Advisors treat equally teens of all races, religions, cultures, sexual orientation and economic levels, with respect and consideration.
6. Advisors use positive techniques or guidance, including redirection, anticipation of and elimination of potential problems, positive reinforcement, and encouragement rather than competition, comparison, or criticism.
7. Advisors will abstain from humiliating or frightening techniques.
8. Advisors will not use profanity in the presence of teens or parents.
9. Advisors will refrain from intimate displays of affection toward others in the presence of teens, parents, and staff.
10. Advisors will portray a positive role model for teens by maintaining an attitude of respect, patience, courtesy, tact, and maturity.
11. Advisors will not fraternize with teens outside the program.
12. Advisors can talk with teens one-on-one in areas away from distraction, yet they must always remain in public view.
13. Advisors will never leave teens unsupervised during YMCA Youth & Government events.
14. Advisors are responsible for the total supervision of their delegation both locally and at the State Conference; they are expected to personally adhere to the "Code of Conduct" and reinforce its value and meaning with their participants, as well as attend the Advisor's training meeting,.

I further understand that if I fail to abide by the rules and regulations of the YMCA, I am subject to removal from the premises of the YMCA and/or removal from participation in YMCA programs and activities without a refund of dues, fees or other amounts paid to the YMCA. I hereby give my permission to the YMCA to use indefinitely, without limitation or obligation, photographs, film footage, or tape recordings which may include my image or voice for the purpose of promoting or interpreting YMCA programs and activities.
I HAVE READ AND VOLUNTARILY SIGN THIS AGREEMENT AND AGREE INDIVIDUALLY TO BE BOUND BY ITS TERMS.

Advisor Name *
Your answer
I understand that writing my name in the box above and checking this box constitutes a legal signature confirming that I acknowledge and agree to the expectations above. *
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