All clubs will receive a confirmation including directions, waiver forms and other pertinent information upon receipt of registration.

Size: px

Start display at page:

Download "All clubs will receive a confirmation including directions, waiver forms and other pertinent information upon receipt of registration."

Geoffrey Mills
6 years ago
Views:

IDENTITY YMCA of Greater Fort Wayne Teen Service Day WHO: Teens in the Fort Wayne area. Must be in grades 6-12.

1 IDENTITY YMCA of Greater Fort Wayne Teen Service Day WHO: Teens in the Fort Wayne area. Must be in grades WHERE: The YMCA of Greater Fort Wayne Central Branch WHEN: December 28 th, :00am-9:00pm COST: $25 per person ADVISORS: One advisor per club must be at least 21 years of age. REGSTRATION INFORMATION Please complete the online registration form by December 15 th, Any registrations after December 15 th may not receive a t-shirt. Final day to register is December 24 th, YMCA and Church Clubs can ask for an invoice of their students and pay the $25.00 registration fees at or within 2 weeks after the event. All liability and medical forms are due at the event. All clubs will receive a confirmation including directions, waiver forms and other pertinent information upon receipt of registration. Link to online registration is: FAX or MAIL: Parkview YMCA Attn: Mell Depew Dawsons Creek Blvd Fort Wayne, IN mellissa_depew@fwymca.org (P): (F):

2 Service Day Schedule 9:00am-9:30am: Arrival/Check In 9:30-10:00am: Ice Breakers and Welcome 10:00am-10:30am: Group Breakout and Travel 10:30am-12:30pm: 3 Station Participation 1. Blue Group: Community Service Project 2. Red Group: Lazer Tag 3. Green Group: Y-Identity and Gym Games 12:30pm: Travel back to YMCA 1:00pm-1:30pm: Lunch 1:30pm-2:00pm: Travel to destination 2:00pm-4:00pm: 3 Station Participation 1. Green Group: Community Service Project 2. Blue Group: Lazer Tag 3. Red Group: Y-Identity and Gym Games 4:00pm-4:30pm: Travel 4:30pm-6:30pm: 3 station Participation 1. Red Group: Community Service Project 2. Green Group: Lazer Tag 3. Blue Group: Y-Identity and Gym Games 6:30pm-7:00pm: Travel 7:00pm-7:30pm: Dinner 7:30pm-9:00pm: Identity Speaker and Worship at First Wayne United Methodist

3 411 ON YOUR BELONGINGS What to Bring Warm Outside Clothes and Tennis Shoes - Clothes may get dirty based on project Gym Clothes and Shoes Medications (if applicable) Water Bottle Positive Attitude! What NOT to Bring Electronic devices or other high value items. Weapons of any kind Bad attitude *The YMCA is not responsible for anything lost or stolen, during the trip.

4 IDENTITY: Teen Service Day will be held at Central Branch YMCA 1020 Barr Street Fort Wayne, IN

5 HEALTH FORM This form must be returned in order to register your teen. Please inform us of any changes in information as they occur. TEEN S INFORMATION Name: (first) (middle) (last) Birthdate: / / Grade Gender: male female Race: Emergency Contact Name Phone: HEALTH INFORMATION IMPORTANT: Please notify YMCA if your teen s information changes. Please give approximate dates: Conditions Allergies Diseases Frequent Ear Conditions Hay Fever Measles Heart Defect Poison Ivy German Measles Convulsions Insect Stings Mumps Diabetes Penicillin Chicken Pox Bleeding Disorders Peanuts/nuts Asthma Other Other Other Operations or serious injuries (please list dates) Chronic or recurring illness Is your child taking any medication? Name of Medication Dose Special instructions Any specific activities to be encouraged? Restricted? Special needs or restrictions (dietary, health, physical, psychological, or educational) for staff awareness: IMPORTANT: Please notify YMCA if your child is exposed to any communicable diseases. Family Physician Phone Dentist/Orthodontist Phone Medical Insurance Carrier Policy # IMPORTANT: MUST BE COMPLETED FOR ATTENDANCE This health history is correct to the best of my knowledge and the child herein described has permission to engage in all prescribed activities except as noted. I hereby give permission to the physician selected by the director to order x-rays, routine tests and treatment for the health of my child, and in the event I cannot be reached in an emergency. I hereby give permission to the physician selected by the director to hospitalize, secure proper treatment for and to order injection and/or anesthesia and/or surgery for my child as named above. Parent/ Guardian Signature Printed Name Date

6 Teen Name: Transportation/Participant Wavier and Release I give my child permission to attend and participate in all YMCA events and activities. I understand this is an on-going program and this registration will be kept on file as long as my child is in a YMCA program. I understand my child herin described has permission to engage in all activities and field trips except as noted by me. In the event I cannot be reached in an emergency, I hereby give permission to the director of the program or his/ her designee to secure emergency medical service, including transportation and a physician. In the case of a medical emergency, every effort will be made to accommodate and treat the person(s) injured. If a trip to the medical facility is necessary, I understand the cost of medical services and medications due to injury or illness during the program time are my responsibility and are to be submitted to my medical insurance provider as primary coverage and then to the YMCA as secondary coverage. I authorize the YMCA to use any photographs, artwork, and projects, etc. of said registered participants for the Purpose of telling the YMCA story and promoting the interests of the YMCA. Parent Name Date Signature Date Phone # Emergency Contact Name Phone # Relationship Cell # Name Phone # Relationship Cell #

September Dear RYLA Coordinator: Rotary Youth Leadership Awards Rotary District 6670 Southwest Ohio Fastfacts:

September Dear RYLA Coordinator: Rotary Youth Leadership Awards Rotary District 6670 Southwest Ohio Fastfacts: September 2017 Dear RYLA Coordinator: Each spring, local Rotary Clubs partner with local school districts to select one or more High School sophomores and juniors (Award Winners) to attend a leadership