MAS Youth Revive Registration Form

MAS Youth Revive Registration

Complete the form below to sign up for our membership service. Spots are limited.
Basic Information
Location *
Which San Diego location are your registering for?
Name of Person Registering *

First Name Last Name
Male/Female *
Grade Level *
Birth Date: *

Month Day Year
Phone Number of Person Registering:

Area Code Phone Number
Parent/Guardian Information
Parent/Guardian 1 *

First Name Last Name
Parent/Guardian Phone Number: *

Area Code Phone Number
Parent/Guardian 2 *

First Name Last Name
Parent/Guardian Phone Number: *

Area Code Phone Number
Contact E-mail *
For announcements, newsletters, changes to the program etc.

Address: *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Emergency Contact Information
Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Relationship *
Relationship to person registering
Allergies/Health Conditions
Please list any allergies or health conditions we should be aware of that might affect the registered person's participation in our program.
Rules and Regulations
Zero Tolerance Policy

Every Youth Leader, Youth Coordinator, or staff member in the Youth Development Program shall have the right to exercise the same authority as to conduct and behavior over the pupils attending the program.

As with any other zero-tolerance policy, there will be consequences for the following types of misconduct:
1. Failure to follow rules, policies and procedure of MAS Youth Revive.
2. General misconduct, including loud or boisterous behavior that tends to disturb other members, and includes running in the classroom/halls, minor defacement of property, and pushing or shoving others.
3. A members' persistent refusal to follow the instructions of program staff, program administrators, or any revive employee or volunteer. This shall also include a member’s refusal or failure to properly identify oneself on request.
4. Use of obscene, vulgar, profane, disrespectful, demeaning or threatening words and/or actions or gesture directed to or in the presence of any member or Revive employee.
5. Mutual physical confrontations between member's (fighting).
  Possession and/or use of any tobacco or drug related items or ‘look a like’ items – this may include cigarettes, chewing tobacco and other tobacco-related products, lighters, alcoholic substances, drug-consumption devices, and any substance suspected of being a ‘drug’.
6. A behavior that may result in physical or mental abuse to one’s self.
  Committing an act of indecent exposure in the presence of any other member or staff.
*

I have read, understood, and accepted the Zero Tolerance Policy.
Disciplinary Actions

Failure to follow rules, policies, and procedure of MAS Youth Revive will result in disciplinary action.

Disciplinary actions will be carried out according to the following procedure:
1. Verbal reprimand.
2. Special assignments or removal from activity or lesson.
3. Parent contact.
4. Suspension from program.
5. Permanent withdrawal from program.
*

I have read, understood, and accepted the Disciplinary Actions.
Attendance Policy

Neither MAS San Diego Employees or MAS Youth Revive Staff can be held responsible for students and families who neglect to follow the attendance procedures in place. As a result of our need to ensure the safety of our members, as well as the goals of our program, the following policies must be followed:
1. Members enrolled in MAS Youth Revive are expected to attend on all scheduled program days including hikes and field trips.
2. If a member is not going to be attending on a regularly scheduled day, we asked that Program Staff be notified by 1:00 pm (858-248-9635) that day or prior to the absence.
3. Failure to attend three regularly scheduled days without notification to the Youth Leader or any other program staff will result in the member being placed on suspension from MAS Youth Revive, until the issue of non-attendance is addressed by the Youth Coordinator and the parent/guardian. Notification of suspension will be conducted by phone.
4. Inconsistent or lack of attendance will result in the member’s name being removed from the attendance roster. Notification for attendance roster removal will occur by phone or written correspondence.
*

I have read, understood, and accepted the Attendance Policy.
Privacy and Confidentiality Practices
Confidentiality Policy

It is the policy of MAS Youth San Diego to protect the confidentiality of its participants and their families. With the exception of the limitations listed below, program staff will only share information about members and their families with other professional staff and. Furthermore, all prospective members and parents/guardians should be informed of the scope and limitations of confidentiality by program staff.

In order for MAS Youth Revive to provide a responsible and professional service to participants, it is necessary to ask members and parents/guardians to divulge extensive personal information about the prospective members and their families, including:
- Information gained during program participation.
- Members’ names and images gained from participants themselves, program meetings, training sessions, and other events.
*

I have read, understood, and accepted the Confidentiality Policy for membership.
I grant to MAS Youth San Diego, its representatives and employees the right to take photographs of my child in connection with MAS Youth Revive's publicity and advertising material. *

Agree Decline
Liability and Injury Release
Liability Release and Parental Consent Form

In consideration of the acceptance of my application for the above program, I hereby waive, release, and discharge any and all claims for damages for personal injury, property damages or which may hereafter occur to me as a result of participation in MAS Revive. This release is intended to discharge in advance MAS San Diego, its officials, employees, volunteers and agents from liability, even though that liability may arise out of perceived negligence on the part of persons mentioned above. It is understood that some recreational activities involve an element of risk or danger of accidents, and knowing those risks, I hereby assume those risks. It is further understood and agreed that this waiver, release, and assumption of risk is to be binding on my heirs and assignees.
*

I give consent for my child to participate in the above activities, and I execute the above liability release on their behalf.
Consent for Treatment

I hereby give my consent to have the above applicant treated by emergency medical personnel, a physician, or surgeon, in case of sudden illness or injury while participating in the above activity. It is understood that MAS Revive will provide no medical insurance for such treatment, and that the cost there of will be at my expense.
*

I have read and understood the foregoing registrationliability release and parental consent form, and agree to all of its terms andconditions.
Electronic Signature
Print name of parent/guardian *
Print name of registering member *
Submission of the application does not guarantee you a spot in our program. We will contact you shortly to complete your membership application if a spot is available.

Thank you!
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MAS Youth Revive Registration

Basic Information

Parent/Guardian Information

Emergency Contact Information

Allergies/Health Conditions

Rules and Regulations

Privacy and Confidentiality Practices

Liability and Injury Release

Electronic Signature