UYP 2022 Scholarship Application | Families Together in NYS

FTNYS continues to monitor the ongoing developments of the COVID-19. The health and safety of our FTNYS community are of the utmost importance. We are excited about safely gathering in Albany, NY, on June 24-27, 2022

We abide by and enforce all guidelines set forth by the City of Albany and New York State. Per these guidelines, beginning on February 10, 2022, requirements for vaccine verification, proof of negative test, and masks have been lifted.

MASKS - Although the mask requirement in NYS has been lifted, attendees are strongly encouraged to wear masks.

Applicant Information

First Name *

Last Name *

Pronoun

Such as: He/Him, She/Her, They/Them

Organization

Job Title

Date of Birth *

If you are under the age of 18 you are only eligible for the Disability Leadership Track and you will share hotel accommodations with your parent/caregiver at the Staybridge Hotel.

Phone *

Email *

County

Emergency Contact Name

Emergency Contact Phone Number

Major *

If you selected Disability Leadership Major, will your parent(s)/caregiver(s) be attending the Parent Track (Foundations in Leadership) at the Staybridge Hotel?

Yes No

If your parent/guardian(s) are participating in Foundations for Leadership, list their full names here:

Accompanying Parent/Guardian Email

Accompayning Parent/Guardian Cell

T-Shirt Size

Will you be bringing a support person?

Yes No

A support person must register and pay for attendance. Support individuals must register at bit.ly/UYP22SP

List any disability accommodations

Dietary Restrictions:

Please list all allergies and special dietary needs

I agree to become a member of Youth Power.

I agree

I hereby consent to and authorize the use of information for publication purposes to: New York State Developmental Disabilities Planning Council and Families Together in New York State. I consent to and authorize the use, publication, and reproduction of any and all photographs, digital images, videotapes or recordings made of me, and the right to copyright and/or use, reuse, modify, and/or publish, republish photographic pictures, digital images, videotapes or recording in conjunction with my name. I also give permission for the photographs, digital images, videotapes, or recordings to be used in their entirety and/or edited versions, as deemed necessary, including the use of images on agency-operated websites. Furthermore, permission is also given for the photographs, digital images, videotapes, or recordings to be used at any time in the future without further clearance from me. I have read the release and agreement. Before signing below, I authorize that I fully understand the contents above.

Photo and Video Release

I agree I disagree

Anyone under the age of 18 will be residing with their parent at the Staybridge Hotel located at 39 Wolf Rd, Albany, NY 12205. All students 18-30 will be sharing as dorm style room with a UYP peer participant.

If you would like to request a roommate, please list their name below

I have legal authority to register myself or this youth for this event and I give permission for this youth to attend UYP. If under 18, I understand that this youth must be supervised by the accompanying parent, caregiver, or chaperone. This youth agrees to abide by the rules of the conference. I understand that FTNYS and its staff are not responsible for monitoring this youth and I will not hold Families Together in NYS liable in the event of injury. I agree to the liability statement above.

Liability Statement

Yes No

Youth Scholarship Information

Please answer the questions below. We cannot award scholarships to individuals who have not fully completed this applications and signed below. All youth are required to complete this application themselves or with assistance as needed.

Are you currently employed as a YPA (Youth Peer Advocate)? *

Yes No

Why do you want to attend this conference? Please provide a brief paragraph detailing how you plan to bring your conference experience back to your community and benefit other family members and/or youth.

Are you affiliated with a family support program, youth group, coalition, support group, or advocacy organization? *

Yes No

Do you currently hold any position leading or taking part in systems change efforts? *

Yes No

Have you ever attended UYP in the past?

Yes No

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 Conduct

Please type your name to sign

Signature *