Leaders UnPlugged Registration Form – Connections Unplugged

Leaders UnPlugged

Registration Form

Step 1 of 6

Today's Date*
MM slash DD slash YYYY
Program Eligibility*
This program is an extracurricular activity that uses games and activities in nature to provide valuable leadership training skills to youth. Please check the boxes that may apply to your teen so that we can make sure we are the best fit.
- Select All
- My teen does not have a history of substance abuse AND is not currently using drugs or alcohol.
- My teen is not currently engaging in self-harm behaviors.
- My teen is interested in attending this program voluntarily.
- My teen does not display defiant behaviors to adults in authority roles (teachers, group leaders, etc).
- My teen can calm themselves down with the assistance of an adult if they become upset. My teen does not display aggressive or violent behaviors.
Summer 2021 Class Registration*
Classes held on Monday 3:30-5:30PM at Mickler's Landing Beach Access Summer A: 6/7, 6/14, 6/21, 6/28 Cost: $225 Summer B: 7/5, 7/12, 7/19, 7/26 Cost: $225
How many members would you like to sign up for Leaders UnPlugged?*
Member's Name*
First Last
Member's Date of Birth*
MM slash DD slash YYYY
Member's Phone Number*
Member's Email
Member #2: Name*
First Last
Member #2: Date of Birth*
MM slash DD slash YYYY
Member's Phone Number*
Member's Email
Member #3: Name*
First Last
Member #3: Date of Birth*
MM slash DD slash YYYY
Member's Phone Number*
Member's Email
Member #4: Name*
First Last
Member #4: Date of Birth*
MM slash DD slash YYYY

Member's Legal Guardian*
First Last
Relationship to Member*
Please list your relationship to the Member(s) for whom you are filling out this registration form for.
Text Message and Email Communication Consent*
We will only communicate important registration, weather, and health information via email and text message. Your personal contact information will remain confidential and only used by Connections UnPlugged for the purpose of communicating program information.
I agree to receive text messages and email communication about program updates.
Contact Phone #*
Email*
Address*
Street Address Address Line 2 City State ZIP Code
Do you wish to add a second home address for the Member?*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Program Size Consent*
We must have 5 members signed up to run this program.
By checking this box, I acknowledge that program availability is dependent upon enough eligible participants being registered.
Program Rates Consent*
Leaders Unplugged Program cost is $225 per 4-week class, per participant. Summer A and Summer B run in 4 week increments. Program fees are due at the time of sign up. A 3% credit card convenience fee is applied to payment at checkout. Payment by cash or check is also accepted to avoid credit card fees.
By checking this box, I acknowledge that all sales are final.
Program Weather Policy*
Leaders Unplugged will run programming according to the scheduled dates. In the case of severe weather (hurricanes, tropical storms, tornados, flooding) class will be cancelled. In the case of thunderstorms, class may be held indoors at an alternative location or rescheduled to Wednesday at the same time and location. If multiple classes are cancelled due to weather, they will be rescheduled to a later date.
By checking this box, I acknowledge understanding the weather policy.
Media Consent*
I hereby grant permission to Connections UnPlugged, Inc. to take and use photographs, videotape and/or digital images of my child for use in publicity, illustration, publishing (including publishing in electronic form), or other lawful uses as may be determined by Connections UnPlugged. I authorize the use of these images indefinitely without compensation to me. All negatives, positives, prints, digital reproductions and videotape shall be the property of Connections UnPlugged.
- I agree to the media consent and state that my child's name and identity MAY be revealed in descriptive text or commentary in connection with the use of such image(s).
- I agree to the media consent and state that my child's name and identity MAY NOT be revealed in descriptive text or commentary in connection with the use of such image(s).
- I DO NOT AGREE to the media consent on behalf of my child.

Medical Information*
Are there any medical issues that we need to be aware of (returning members: any new medical issues)? Our team is trained in First Aid and CPR, however we can be of best help during an incident if we have up to date medical history and/or medications the member is currently taking. Please note this information is confidential and will not be disclosed at any time.

Medical Diagnosis and Medications*

Please include any Allergies to this list (any new for returning members). TO ADD ANOTHER ROW CLICK THE (+) SYMBOL.

Member Name	Medical Diagnosis	Medication Prescribed	Any Precautions To Be Aware Of?

Developmental Information*
Are there any developmental issues that we need to be aware of? Our team is clinically trained in the field of behavioral health. Please note this information is confidential and will not be disclosed at any time.

Developmental History*

TO ADD ANOTHER ROW CLICK THE (+) SYMBOL.

Member Name	Developmental Diagnosis	Therapies Currently Attending	Any Precautions To Be Aware Of?

Academic Information*

TO ADD ANOTHER ROW CLICK THE (+) SYMBOL.

Member Name	Current Grade Enrolled In	Current Academic School / Program Enrolled In

Technology Information*
Please share the technology habits in your home. What is the average screen time exposure each day? Are there any limits provided for technology? Are there any concerns you have about the Member's use of technology, gaming, or social media? Is the Member's sleep or mood disrupted by use of technology? Please describe.
EcoWellness Information*
Please share the relationship the Member has with nature. What activities does the family enjoy in nature? Are there hobbies that the Member enjoys? Are there any barriers that your family experiences in spending time outdoors?
Emotional Safety*
Has the Member's experience include an incident that may impact their ability to feel safe during our time together? We want to make sure that all activities are carried out with the best interest of our Members. This information will remain confidential and will help us to make this a safe, enriching space. For RETURNING Members, please update us on any new occurrences.
Emotional Safety*
Please share any trauma-related triggers (i.e. loud noises) and specific trauma-response (i.e. panic) so that we can be mindful of this during our time together.