Power Up Registration

Power Up is a YMCA of Fredericton initiative to engage youth (ages 12 - 15) in community activities while fostering life skils and personal growth. This trauma informed program provides opportunities for leadership development and social engagement to empower young leaders to reach their full potential.

Name of Youth Participant *

First

Last

Date of Birth *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email *

Date would for

Phone *

Emergency Contact Name *

Emergency Contact Phone *

Eligibility Requirements

Participants are ages 12 - 15 at the start of the program.
Meetings are mandatory; 3 consecutive missed meetings will result in removal from the program.
Annual re-assessment is required to track progress and ensure YMCA eligibility.
Youth agree to engage in the program and adhere to a communally developed code of conduct.

Agreement *

I, the undersigned, hereby consent to the use of my child's photograph or likeness in any publication, videotape, pamphlet or promotion by YMCA or other agencies, which are promoting or furthering the mission of the YMCA. By signing this consent, I understand that I am releasing YMCA from any and all liability that may occur as a direct or indirect result of the photograph, the release of identity, or the public relations materials, including but not limited to the use of any quotations.
I, the undersigned hereby consent to my child's participation in the Power Up Program and release the YMCA and all subsidiaries from any liability that may arise through participation in said program.

Date *

Signature of parent or guardian *

Tell Us About Yourself - Power Up!

Please share with us some information about what you hope to gain from the Power Up Program. In the event that we receive more applications than spaces available, these answers will be used to determine which youth should join the program.

Youth who are most eligible are those who may not have access to similar programming at school, in their community, those who could benefit from access to social programming with peers, leadership development and access to YMCA's facilties.

What are some activities, interests and hobbies you enjoy as a family? *

Do you have any dietary restrictions we need to know about? (Eg. Halal, Gluten Free, Vegetarian, Lactose intolerant, allergies, etc.) If not, please mark N/A *

What are some interests and hobbies you enjoy when you have time for yourself? *

Returning Participants: How can we improve the program? What workshops and activities would you like to see? If unsure, please mark "unsure". *

Agreement *

I, the undersigned, hereby consent to my child's participation in the Power Up Program and release the YMCA and all subsidiaries from any liability that may arise through participation in said program.

Date *

Signature of Parent or Guardian *