Unitarian Universalist Fellowship of Manhattan

Name*

First NameLast Name

Phone Number*

Area CodePhone Number

E-mail*

Address*

Street Address

Street Address Line 2

CityState

Zip Code

I am a...*

Youth (grades 7-12 or equivalent)Adult (25 and up)Youth Staff

Yes, I understand and agreeNo, I do not agree

Parent/guardian signature*

Date

MonthDayYear

Parent/guardian phone number *

Area CodePhone Number

Alternate emergency contact person*

Alternate emergency contact phone number*

Area CodePhone Number

Health insurance company

Policy holder name

Policy number

Physician's name

Physician's phone number

Area CodePhone Number

Behavior Expectations

(To be read by youth, adult sponsors, and parents/legal guardians)

I agree to the following during the conference (applies to youth and adult sponsors):

I will not bring or use tobacco products, illegal drugs, alcohol, or caffeine products.

I will not engage in sexual behavior which detracts from the conference community.

I will not bring weapons, explosives, or pets to the conference.

I will remain onsite at all times unless permission to leave is given by conference staff.

I will abide by the rules of the site and the laws of the city/state in which the conference is held.

I will practice self care, physically (getting enough sleep, healthy eating), and emotionally (seeking appropriate allies and professionals to help process my feelings and concerns).

I will contribute to the conference community being created and attend all mandatory activities.

Youth signature*

Date*

MonthDayYear

Photo consent*

I give consent for my youth's photo and/or electronic media image to be used in congregational and regional bulletin boards, newsletter, website, and official social media pages.I do NOT give consent for my youth's photo and/or electronic media image to be used in congregational and regional bulletin boards, newsletter, website, and official social media pages.

I agree to pay registration...*

in advance by check sent via mail (made out to UUFM) $10 per personat time of check in by cash, check, or credit/debit card $10/$11now with credit/debit card $11

Type a question

Helping Hands DonationBlessing Box DonationPledge/General DonationOther

Total amount*

USDwhat

Credit/Debit Card