Safe Harbor Cohasset Coalition

YouTH AMBASSADORS REGISTRATION FORM

Please complete the following registration form with a parent or guardian.

YouTH SECTION

Youth Ambassadors is a program that is youth-led and facilitates lasting relationships between the youth of Cohasset, builds leadership skills, and raises awareness around health issues affecting the Cohasset community. Youth Ambassador’s mission is to empower each individual to address local situations and take action in order to improve their access to resources and impact their selves, their peers, and their community. This is achieved by providing youth with a core base of knowledge of the issues, identifying and practicing core skills needed to successfully take action, and providing an opportunity to put the skills into action.

Expectations

It is important to understand that as a Safe Harbor Youth Ambassador, you take on the responsibility of role-modeling and promoting a healthy, educated, responsible lifestyle to your peers and your community.

By joining Youth Ambassadors, you commit to:

Attending at least 75% of weekly meetings throughout the school year
Communicating absence/tardiness in a timely manner- must be emailed to cohassetyouthambassadors@gmail.com.
Dressing appropriately and professionally when representing the organization at specific events
Not engaging in any alcohol, tobacco products, marijuana products or any other illegal drug use
Participating in group discussion
Leaving phones out of sight for the duration of the meetings to minimize distraction
Practicing communication by responding to emails and texts

RESPONSIBILITY

We understand that there will be times you are unable to make meetings. All we ask is that you let us know in advance via text, call, email. To promote leadership and responsibility, we expect that these notifications will come from you and not your guardian.

RELIABILITY

Like we mentioned, there will be times where you just can’t make it. However, there will be projects you’re involved in where others will be relying on you to play your part. Please connect with other members if you’re unable to make a meeting and plan, if necessary, to meet up with them another time to continue your work.

RESPECT

Throughout the year, we will continuously practice and polish presentation skills, practice PSAs, and edit press releases. This is a place where mistakes can be made, and constructive criticism can be given. The goal is to empower each other to grow and improve. We expect that any feedback will be given respectfully and that mistakes will be embraced and not mocked.

MEETINGS

Meetings take place every Wednesday (unless noted) from 6:30-7:30 in the meeting room of the Paul Pratt Memorial Library (35 Ripley Road, Cohasset, MA). Pizza is provided.

WHO TO CONTACT

Not sure where to meet? Going to be late? Question about an upcoming project? Please email cohassetyouthambassadors@gmail.com to let us know and receive an excused absence.

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Thank you for registering for Cohasset Youth Ambassadors!

Please note, your registration will not be complete until the Parent/Guardian section on this page is submitted. We’ll be in touch about the meeting schedule for this upcoming semester via email so keep an eye out for information. Please email cohassetyouthambassadors@gmail.com with any questions.

Student Name

Student Email

Student Phone

Is it okay to text program information to this phone number?

Date of Birth (YYYY-MM-DD)

Grade

Address

T-Shirt Size

Parent/Guardian SECTION

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Thank You!

Thank you for registering for Cohasset Youth Ambassadors! We will be in touch with you about the meeting schedule for this upcoming semester. Please email cohassetyouthambassadors@gmail.com with any questions. This year, we are going to expand the parent/caregiver involvement in the Youth Ambassador Program. Parents and caregivers, please fill out this survey to complete registration: https://www.surveymonkey.com/r/GJYRBSP Thank you and we look forward to hearing your thoughts!

Student Full Name

Parent/Guardian Full Name

Parent/Guardian Email Address

Parent/Guardian Phone

ACTIVITIES PERMISSION

I declare by signing this form that I am the legal parent/guardian of minor child and student (hereinafter “student”) of the Safe Harbor Cohasset Coalition Youth Ambassador Program and am authorized to grant permission for the activity planned by the program. I hereby authorize student to participate in off-location field trips and all related activities. Student has my permission to ride in the car of an adult volunteer, driven by that adult. By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.

I hereby consent to participation by student in the special events planned by the program. I understand that these events will take place away from regular program location and that student will be under the supervision of the designated employees and volunteers on the stated dates. I further consent to the conditions stated above on participation in these events, including the method of transportation. In consideration of student being allowed to participate in programs and special events, I agree to release and hold harmless the Safe Harbor Cohasset Coalition, any and all affiliated organizations, their employees, agents and representatives, including volunteer and other drivers from any and all claims arising from or relating to student’s participation. This Release and Hold Harmless Agreement does not apply to claims or intentional misconduct or gross negligence. By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.

LIABILITY WAIVER

COMPREHENSIVE MEDIA WAIVER

I understand that Youth Ambassador Program and Safe Harbor Cohasset Coalition activities frequently result in media coverage. I agree to allow my child’s photo or statements to reporters to be used in any news account, press release, or media report on Youth Ambassador Program activities; whether TV, radio or print. My child may volunteer to participate in the production of any radio or video or TV PSA or media appearance associated with Youth Ambassador Program. My child’s photo may appear on the Safe Harbor Cohasset Coalition web site and associations/partnerships of Safe Harbor Cohasset Coalition and he or she may participate in videos produced by Safe Harbor Cohasset Coalition and all other associations and partnerships. I understand that the Youth Ambassador Program retains ownership and use rights for these media productions and no compensation is provided. I waive and release for myself and my minor children all rights and claims for compensation or damages for such use of these audio, visual and/or written materials. By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.

35 Ripley Road,
Cohasset, MA 02025
(781)-783-5293

safeharborcohasset@gmail.com