Teen Achievers Registration

STUDENT INFORMATION

Student's Full Name(Required)

First Middle Last

Date of Birth(Required)

Gender(Required)

Male

Female

Non-Conforming

Other/Prefer not to answer

Current Grade Level:(Required)

5th

6th

7th

8th

Grade Entering in Fall:(Required)

6th

7th

8th

School Attending (in Fall)(Required)

Student's Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone

Ethnicity(Required)

Hispanic or Latino

Not Hispanic or Latino

Race(Required)

American Indian or Alaska Native

Asian

Black or African American

White

Native Hawaiian or Other Pacific Islander

Prefer not to say

Other

Select all that apply

Other Race(Required)

PARENT / LEGAL GUARDIAN INFORMATION

Primary Parent / Legal Guardian(Required)

First Last

Primary Guardian Address(Required)

Same as previous

Street Address Address Line 2 City State ZIP Code

Primary Guardian Cell Phone(Required)

Primary Guardian Home Phone

Primary Guardian Email(Required)

A copy of your completed registration form will be sent to this email address for your records.

Primary Guardian Work Address

Street Address Address Line 2 City State ZIP Code

Primary Guardian Work Phone

Would you like to add a Secondary Parent / Legal Guardian?(Required)

Yes

No

Secondary Legal Guardian(Required)

First Last

Secondary Guardian Address(Required)

Same as previous

Street Address Address Line 2 City State ZIP Code

Secondary Guardian Cell Phone(Required)

Secondary Guardian Home Phone

Secondary Guardian Email

Secondary Guardian Work Address

Street Address Address Line 2 City State ZIP Code

Secondary Guardian Work Phone

Special Custody Concerns

This Section must be signed even if there are no concerns.

Are there any custody concerns regarding this student that we need to be aware of while the student is in our care? Please attach any documentation (court order, etc.) to back up all custody concerns.(Required)

No

Yes, please explain

Explain Custody Concerns(Required)

Attach a copy of your current court order

Drop files here or

Max. file size: 100 MB.

KENOSHA YMCA RELEASE, INDEMNIFICATION AND HOLD HARMLESS AGREEMENT(Required)

I have had sufficient time to read this entire document and, should I choose to do so, consult with legal counsel prior to signing.

In consideration of participating in YMCA activities, and for other good and valuable consideration, I hereby agree to release and discharge from liability arising from negligence Kenosha YMCA and its owners, directors, officers employees, agents, volunteers, participants, and all other persons or entities acting for them (hereinafter collectively referred to as “Releasees”), on behalf of myself and my children, parents, heirs, assigns, personal representative and estate, and also agree as follows:
1. I acknowledge that participating in YMCA activities involves known and unanticipated risks which could result in physical or emotional injury, paralysis or permanent disability, death, and property damage. Risks include, but are not limited to, broken bones, torn ligaments or other injuries as a result of falls or contact with other participants; death as a result of drowning or brain damage caused by near drowning in pools or other bodies of water; medical conditions resulting from physical activity; and damaged clothing or other property. I understand such risks simply cannot be eliminated, despite the use of safety equipment, without jeopardizing the essential qualities of the activity.
2. I expressly accept and assume all of the risks inherent in this activity or that might have been caused by the negligence of the Releasees. My participation or participation by any minor on this membership in this activity is purely voluntary and elect to participate despite the risks. In addition, if at any time I believe that event conditions are unsafe or that I or any of the minors on this membership are unable to participate due to physical or medical conditions, then I will immediately discontinue participation.
3. I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless Releasees from any and all claims, demands, or causes of action which are in any way connected with my or any minors on this membership participation in this activity, or my or any minors on this membership use of their equipment or facilities, arising from negligence. This release does not apply to claims arising from intentional conduct. Should Releasees or anyone acting on their behalf be required to incur attorney’s fees and costs to enforce this agreement, I agree to indemnify and hold them harmless for all such fees and costs.
4. I represent that I have adequate insurance to cover any injury or damage I or any minors on this membership may suffer or cause while participating in this activity, or else I agree to bear the costs of such injury or damage myself. I further represent that I or any minors on this membership have any medical or physical condition which could interfere with safety in this activity, or else I am willing to assume - and bear the costs of - all risks that may be created, directly or indirectly, by any such condition.
5. In the event that I file a lawsuit, I agree to do so in the state where Releasees’ facility is located, and I further agree that the substantive law of that state shall apply.
6. I agree that if any portion of this agreement is found to be void or unenforceable, the remaining portions shall remain in full force and effect.

The Clubhouse Code of Conduct(Required)

I have read, understand, and agree to adhere to The Clubhouse Code of Conduct.

The Clubhouse strives to provide a safe, comfortable atmosphere, in which members of the Clubhouse Community may explore their own creativity. To that end, the Clubhouse Council has developed this Code of Conduct. You are now asked to agree to the following:
1. All members of the Clubhouse Community are encouraged to explore their own creativity. I will help this happen by not doing anything to disrupt or discourage another's creative expression.
2. I know that the Clubhouse is everyone's space. If I choose to play music or sound files, I will play it so that it does not disturb others. In addition, I will not play any music containing profanity. I will also adhere to the Clubhouse Internet Safety Guidelines so that no one in the Clubhouse will be exposed to inappropriate material and/or people who wish to misuse the Internet (the Internet Safety Guidelines are on the other side of this paper).
3. In an attempt to make everyone feel comfortable in the Clubhouse, I will not use profanity and/or discriminatory language. In addition, I will not use language that purposefully offends another member of the Clubhouse.
4. In an effort to ensure the safety of everyone in the Clubhouse Community, I will not steal, pirate software, or engage in any other illegal activity, including possession and/or use of narcotics or weapons.
5. I realize that the Clubhouse is limited in resources, and we are lucky to have all the equipment that we have. I will do my best to respect the Clubhouse space. I will not purposefully destroy or vandalize any property of the Clubhouse or of another Clubhouse Community member. I will also help to keep the Clubhouse clean by picking up after myself.
6. The Clubhouse is filled with different kinds of people from various backgrounds. I will help create a feeling of community by respecting everyone I come in contact with and treating them how I would want to be treated. Both physical and verbal fighting will not be tolerated. If I have a problem I cannot solve peacefully myself, I will talk to a staff member and allow them to handle it.
If the code of conduct is broken, I will be subject to the following disciplinary action:
• For a minor infraction (cursing under my breath, rough housing, not following staff instructions, etc.), I will be warned by a member of the staff. If I get warned three times in one day, I will be asked to leave and be suspended for one day. If this behavior becomes habitual, the staff will take appropriate action.
• For a major infraction (getting into a verbal altercation, vandalism, verbal abuse of another member, etc.), I will be asked to leave and be suspended for one week. If this behavior becomes habitual, the staff will take appropriate action.
• For engaging in physical violence and/or illegal activity -- as mentioned in number 4 -- in or near the Clubhouse, I will forfeit my membership.
If you violate the Code of Conduct and are subject to suspension, a member of the staff will sit down and discuss the situation with you before any disciplinary action is taken. You will be given an opportunity to explain your actions and advocate on your own behalf.