Welcome to the University of Youth Power registration! UYP Registration Information First Name: * Last Name * Pronoun Such as: He/Him, She/Her, They/Them Organization Job Title Date of Birth * Phone * Email * County - select County - Albany Allegany Bronx Broome Cattaraugus Cayuga Chautauqua Chemung Chenango Clinton Columbia Cortland Delaware Dutchess Erie Essex Franklin Fulton Genesee Greene Hamilton Herkimer Jefferson Kings Lewis Livingston Madison Monroe Montgomery Nassau New York Niagara Oneida Onondaga Ontario Orange Orleans Oswego Otsego Putnam Queens Rensselaer Richmond Rockland St. Lawrence Saratoga Schenectady Schohaire Schuyler Seneca Steuben Suffolk Sullivan Tioga Tompkins Ulster Warren Washington Wayne Westchester Wyoming Yates Emergency Contact Name * Emergency Contact Phone Number * Major * - select Major - Peer Advocacy - This major is for young people focused on promoting self-advocacy through empowerment and shared lived experience. Systems Advocacy - This major is for young people focused on systems change and using their voices to influence policies, practices, regulations, and laws. Recovery Advocacy - This major is for young people focused on understanding substance use recovery, supports, and services. T-Shirt Size * - select T-Shirt Size - XXS XS S M L XL XXL 3XL Will you be bringing a support person? Yes No If you are bringing a support person, they MUST register separately. List any disability accomodations * Dietary Restrictions: * Gluten Free Kosher None Vegan Vegetarian Other (Please specify in special requests field below) Please list all allergies * I agree to become a member of Youth Power I agree If you would like to request a roommate, please list their name below I give permission to Families Together to photograph and/or videotape this registered attendee and to use his or her image in photographs, video, and/or film for the purpose of promoting the mission, activities, and programs of Families Together. I understand that this registered attendee and his/her parent/guardian/legal authority is not entitled to any compensation or rights in these materials, and I release Families Together from any liability for the use of this registered attendee's image for the above stated purpose. Please check. Photo/Video Release I agree Code of Conduct: I have chosen to attend this event and will participate in discussions and activities. I will help to create a youth peer community based on mutual respect and a sense of personal well being. I agree to refrain from sexual behavior and public displays of affection while attending the YP event. I will not bring or use any weapons, firearms, or anything that may be construed as a weapon. I will not possess, use, or distribute any illegal drug or drug paraphernalia. I will not commit any illegal activity. I will treat others with honor and respect. Code of Conductt I agree Event Fee(s) Event Fee(s) * Resident Student - $ 450.00 Day Student - $ 350.00 Total Payment Options Payment Method Pay Online via Credit Card Pay via PayPal I will pay later Credit Card Card Type - select - Visa MasterCard Amex Discover Card Number * Security Code * Expiration Date * -month- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec -year- 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 Billing Name and Address Billing First Name * Billing Middle Name Billing Last Name * Street Address * City * Country * - select - United States State/Province * - select State/Province - Alabama Alaska American Samoa Arizona Arkansas Armed Forces Americas Armed Forces Europe Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas United States Minor Outlying Islands Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Postal Code * UYP Demographic Info Help us know more about the diversity of UYP students. Which of these best describe you? Please check all that apply. Young person involved with foster care, juvenile justice, substance abuse, mental health, developmental disability, special education services Youth Advocate Other (Please Describe) Other (Please Describe): Race/Ethnicity * African American Asian/Pacific Islander European/Caucasian Hispanic/Latin Native American Another not listed Mutiracial Do you identify as part of the LGBTQIA+ community? * - select Do you identify as part of the LGBTQIA+ community? - Yes No No, but I am an Ally Prefer not to say Do you have a disability? If so, check all that apply. * Developmental/Intellectual Emotional/Behavioral Health Hearing Learning Mobility Visual Other No disability Physical Disability Other Disability Not Listed Above What systems/services have you been involved in? (Check all that apply) * Addiction Treatment (AA/NA, Inpatient/Outpatient Services, etc.) Child Welfare (Foster Care, Child Protective Services, etc.) Complex Medical Services/Supports Criminal Jusice (Detention Centers, PINS, Probation, etc.) Developmental/Intellectual Disability Services (OT/PT, Social Skills Training, etc.) Employment Services (Career Centers, Vocational Rehabilitation Services, ACCESS-VR, etc.) Immigration Services Mental Health (Psychiatric Services, SPOA, Therapy Services, HCBS, CFTSS, etc.) Special Education (IEP, 504 Plan, etc.) Temporary and Disability Assistance (SNAP, SSI, SSDI, Temporary Assistance, etc.) Other If other, please describe below Other: Have you been in a residential placement such as a residential treatment facility, community residence, foster boarding home, kinship foster home, or rehabilitation center? * Yes No Leaders Lunch Every year the in-person Leaders Lunch, provides an opportunity for young people and state leaders to speak candidly about real-life issues that youth face while experiencing state systems. What are your top three advocacy issues you wish to discuss with state officials at the Leaders Lunch? State Agency First Choice * Council on Children and Families Development Disabilities Planning Council Families Together in NYS Leadership NYS Education Department Office of Addiction Services and Supports Office of Children and Family Services - Child Welfare Office of Children and Family Services - Juvenile Justice Office of Mental Health Office of Persons with Developmental Disabilities Office of Temporary Disability Assistance The NYS Justice Center State Agency Second Choice * Council on Children and Families Development Disabilities Planning Council Families Together in NYS Leadership NYS Education Department Office of Addiction Services and Supports Office of Children and Family Services - Child Welfare Office of Children and Family Services - Juvenile Justice Office of Mental Health Office of Persons with Developmental Disabilities Office of Temporary Disability Assistance The NYS Justice Center If there are any tables you DO NOT want to be seated at, please indicate below. Any tables you DO NOT want to be seated at Council on Children and Families Development Disabilities Planning Council Families Together in NYS Leadership NYS Education Department Office of Addiction Services and Supports Office of Children and Family Services - Child Welfare Office of Children and Family Services - Juvenile Justice Office of Mental Health Office of Persons with Developmental Disabilities Office of Temporary Disability Assistance The NYS Justice Center Review
