JusticeworX Registration 2023

Youth Participant

First Name

Last Name

Youth Participant Email

non-school email if possible

Home Address

City

State

Zip Code

School

Parish

High School Graduation Year

Youth Participant D.O.B.

mm/dd/yyyy

Gender

MaleFemaleOther

Parent/Guardian Info

Name

First Name

Last Name

DOB (mm/dd/yy)

Email

Primary Phone

HomeCell

Secondary Phone

HomeCell

Emergency Contact Same As Parent/Guardian Info?

Yes

Emergency Contact

First Name

Last Name

Emergency Contact Relationship to Youth Participant

Emergency Contact Phone Number

Medical Information

Youth Participant’s Physician/Practice Name

Youth Participant’s Physician/Practice Phone

In Case of Emergency Info

The Center for FaithJustice’s safety protocol states that in case of an emergency, or non-emergent head injury, severe allergic reaction, deep cut, possible sprains/breaks, vomiting or fever we will CALL you.

For the situations below, please indicate (by selecting ONE) whether you would prefer to be emailed or called with a notification. Both calls and emails will be issued as quickly after the incident as possible.

**Benadryl, advil and motrin will only be given if permission is granted below.:

Scratch/scrape/shallow cut

CALLEMAIL

Administration of Advil/Motrin for cramps/headache

CALLEMAIL

Administration of ice for a non-head injury

CALLEMAIL

Small allergic reaction/given Benadryl

CALLEMAIL

Permission to provide non-prescriptions medication: Please Choose ONE of the following Options:

I hereby GRANT permission for non-prescription medication (such as Tylenol/Advil, Benadryl, cough syrup, etc.) to be given to my child, if deemed advisable by CFJ. I understand that Aspirin will not be given to my son/daughter. I hereby DENY permission for medication of any type, whether prescription or non-prescription to be administered to my child unless the situation is life threatening and emergency treatment is required.

Parent/Guardian Full Name:

Participant Medical Information/Background

Dietary and Medical Information

Medical Matters and Consent

The Center for FaithJustice prioritizes the holistic well-being of every participant that comes on our programs. It is our desire to be as well informed and prepared as possible to meet your child where they are and to respond proactively and compassionately to their needs. We ask that you answer the following health questionnaire and provide any details regarding your child's health that would be beneficial for our staff to know as they accompany them on the program. The information you provide will help inform our leaders and staff on how to best respond to the physical health needs and support the mental health wellness of the participant. This information is only shared with the specific program staff and leaders that directly engage with your child.

Medical Matters

I hereby warrant to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child. Of the following statements pertaining to medical matters, sign only those in accordance with your wishes.

Parent/Guardian Initials

Participant Medical Information/ Physical and Mental Health Background: My child will bring all such medications, clearly marked and labeled, as are necessary. Using a separate sheet of paper, I will provide concise directions that include the names of medications, required dosage and an intake schedule which will be handed in to the team leader at check-in. Please note that failure to indicate, in writing, all prescriptions and non-prescription medications a youth participant is currently taking may result in dismissal from the program.

Parent/Guardian Initials:

In the event that it comes to the attention of the chaperones associated with the activity that my child has become ill with repeated symptoms (such as headache, vomiting, sore throat, fever, diarrhea, etc.), I wish to be contacted immediately. I understand that I may remove my child from the program at any time and at my discretion but acknowledge that refunds are not guaranteed. I further recognize the authority of program staff to remove my child from the program for health or behavioral reasons. In such instances, I agree to pick my child up in a timely manner not to exceed six hours unless agreed upon

otherwise with the program director.

I fully understand the foregoing statements, certify that all information provided is true, and sign this waiver knowingly, freely, and willingly.

Parent/Guardian Signature

Date

Participant Signature

Is the Youth Vegetarian? (Yes will result in vegetarian or vegan meals)

YesNo

My Son/Daughter has a medically prescribed diet

YesNo

Please note the diet:

My Son/Daughter has allergic reactions to the following (include all)

My Son/Daughter has had a medical surgery within the last 6 months

YesNo

Please note any related special needs:

My Son/Daughter is currently under doctor's care

YesNo

Please note any special instructions related to this care:

Will your child be taking medicine while on our program?

YesNo

Note: We require that all prescription medications be administered by our staff while your child on program with us. Medications are to be checked-in with our staff at the program drop off. We additionally require you to report any non-prescriptions medications that your child takes on a regular basis or will need to take during the program week.

Please indicate the medication and include in detail the time of day, how frequently, and how the medication is administered.

Please provide any insight on any side effects to the medication that our staff should be mindful of and/or any additional measures our staff should be taking along with administering the medication.

Please provide in detail insight on any medical, behavioral, emotional, or psychological conditions that are affecting your child's mental wellness (i.e. anxiety, panic attacks & their triggers, history of depression, any behavioral disorders, etc.)

My Son/Daughter has the following physical limitations:

My Son/Daughter has had an episode or been diagnosed with the following (check all that apply):

SeizuresAsthma Diabetic

Immunizations current and up to date?

YesNo

Do you carry medical insurance at this time?

YesNo

Insurance Info

Insurance Carrier:

First and Last Name of Insured:

Insurance ID Number:

Insurance Policy Number:

Name of Employer (providing insurance coverage for youth):

Name of Parent/Guardian Employed:

WorX Program Waiver

This form must be completed by a Parent/Guardian for participants under 18 years of age. Youth participants over 18 years of age may complete this form on their own behalf.

Consent & Liability Waiver

, grant permission for my above named child to participate in WorX programming during the dates indicated above.

I agree on behalf of myself, my child’s other parent(s) and/or guardian(s), and my child named herein, to waive any claim or claims that may be derived from any incident, accident or injury sustained resulting from participation in WorX programming and related activities. I further agree to indemnify, defend and hold harmless: Program sponsors the Center for FaithJustice, affiliated organizations; participating dioceses, parishes and schools, agencies and organizations working collaboratively with
the program; and all staff, volunteers, representatives, and supervisors of the aforementioned institutions. I consent to the mode(s) of transportation used by program staff and representatives.

Policy Consent
This section must be read and reviewed by parents/guardians with youth participant. The parent/guardian and youth participant must indicate having read the following policies and indicate their full consent by initialing next to each. Youth cannot participate in any WorX Program without the full agreement and consent of parents/guardians to program policies.

MEDIA: I understand that multi-media resources (i.e. pictures, video, audio, etc.) may be taken during this event for archival, ministerial/programmatic and promotional purposes (i.e. brochures, WorX videos, website, etc.). By initialing below I recognize and consent to appropriate usage of my child’s image, voice and/or other media content to be used for the materials named above in promoting Center for FaithJustice programs.

Parent/Guardian Initials

Participant Initials

ELECTRONICS/PHONES: Cell phones, smart watches, personal listening devices (i.e. Ipod), and related media are strongly discouraged. If participants are insistent upon bringing these devices, the following guidelines must be observed. Youth participants are free to contact their parents/guardians only at times designated by the program staff. Cell phones and other electronics will be collected from the participants upon arrival and will only be accessible to participants during the times designated by the program staff. Parents can contact their children at any time by calling the Center for FaithJustice hotline which will be provided upon check-in. The location of phones, including those of staff and host sites will be provided for emergency purposes. All participant cell phones will be collected and held by staff for the duration of the daily program. The policy regarding phones is necessary to prevent the constant usage of phones and text messaging and for the safety of participants. The same policy applies for personal listening devices (i.e. iPod), gaming devices and laptop computers. PLEASE NOTE: This policy allows for participants to contact their parents/guardians at all times and is in conformity with safety standards for youth ministry and educational programs.

Parent/Guardian Initials

Participant Initials

CLOTHING & FOOTWEAR: Given agency regulations and community expectations, it is absolutely necessary that participants bring the proper attire for service sites and host churches/schools. Modest clothing is required of all participants at all sites at all times. This applies to both boys and girls and includes: shorts no shorter than 3” above the knee, tee-shirts with sleeves (rather than tank tops, belly shirts, etc.), and appropriate images or texts on clothing (no lewd images or coarse language).

Participants are encouraged to pack enough clothing in case they wish to change after working at their service site and upon return to their host site. Regarding work clothes: given the variety of work youth participants may be doing (from daycare to building houses), you may be expected to wear pants or jeans to your site. All sites require closed toed shoes (sneakers or boots). Sandals and open toed shoes can be worn at the host site but not at work sites. Please pack accordingly. Youth wearing clothing not in compliance with this policy will be sent home.

Parent/Guardian Initials

Participant Initials

ARRIVAL & DEPARTURE: Given its impact on the entire program, late arrivals at and early departures are strongly discouraged. Drop off & pick up times will be provided to parents/guardians. Parent(s)/Guardian(s) must accompany students for drop off/sign in and pick up/sign out.

The Center for FaithJustice has a zero tolerance policy for smoking, drugs, and alcohol on all programs. The possession and consumption of alcoholic beverages is strictly prohibited. Use and/or possession and distribution of drugs and drug paraphernalia are strictly prohibited. Use and/or possession and distribution of prescription drugs without proper medical documentation is also strictly prohibited. Note that this includes all illegal materials as well as vaping substances including THC, cannabis, CBD, etc.

Parent/Guardian Initials

Participant Initials

DRUGS & ALCOHOL: The Center for FaithJustice has a zero tolerance policy for smoking, drugs, and alcohol on all programs. The possession and consumption of alcoholic beverages is strictly prohibited. Use and/or possession and distribution of drugs and drug paraphernalia are strictly prohibited. Use and/or possession and distribution of prescription drugs without proper medical documentation is also strictly prohibited. Note that this includes all illegal materials as well as vaping substances including THC, cannabis, CBD, etc. Violation of the above will result in the participant's immediate dismissal from the program. Furthermore, if a participant gives any leader or staff member suspicion of being in violation of the above, CFJ reserves the right to search the participant's personal items. NB: If you are a participant on ServiceworX, JusticeworX, or NeXt Level as part of a high school or parish group, the codes of conduct in place at said high school or parish also apply. Violation of those institutional policies relative to substance abuse could result in suspension or expulsion in addition to dismissal from your WorX experience. Please familiarize with the disciplinary manual.

Parent/Guardian Initials

Participant Initials

FINAL NOTE: The above policies have been developed over the years to provide parents/guardians and participants with maximum information and to foster the safest, most effective ministry experience possible. In addition to the above, staff will review all program guidelines with participants as part of their orientation to the program. Given the importance of the policies, failure to comply may, regrettably, result in a participant’s dismissal from any WorX Program. In the case of dismissal, parents/guardians will be contacted to arrange picking up the youth participant. There will be no refund in the case of dismissal. By initialing below the parent/guardian acknowledges this policy and agrees to comply with decisions made by staff relevant to the enforcement of the program guidelines.

Parent/Guardian Initials

Participant Initials

Dismissal Policy

Warning Policy: Certain misdemeanors on program will result in an official warning given by the program and/or CFJ staff. CFJ holds the right to ask participants to leave the program if the misdemeanors continue to happen after a warning has been given. Behaviors, actions, or situations that will result in an official warning include but are not limited to the following:

Bullying of any nature: CFJ has a no tolerance policy for bullying of any form. By coming on a program, participants agree to uphold and respect the dignity of each person they encounter. If a participant (or group of participants) are seen to be instigating and/or perpetuating a situation that makes another participant (or group of participants) uncomfortable or that the staff deems as inappropriate including, but not limited to, inappropriate comments, intentional exclusion, or use of social media platforms to make discriminatory or inappropriate remarks, the team leader and/or CFJ staff hold the right to speak with the participant(s) directly to investigate the situation and given an official warning if necessary.
Leaving the group and/or service sites: By coming on the program, participants agree to stay with their designated group and program staff whether they are at the host site or service site. Under no circumstances should participants leave their group or leader without first informing and getting permission from the program staff. Should a participant leave their service site and/or any spaces where the whole group is meant to be together without prior permission from a leader, CFJ holds the right to give the participant an official warning.
Leaving one's designated bed and/or room at night: Participants are assigned rooms and bunks (depending on the program location) at the beginning o the week. Under no circumstances should participants be in a room that is not their own without the permission of a program staff. Should a participant (attempt to) leave their room after lights out to go to a different one, they are in direct violation of this ground rule. The tam leader and/or CFJ staff hold the right to speak with the participant(s) directly to understand their reason for leaving their room and to give the participant an official warning.
Reckless treatment of property/equipment: Participants agree to respect and take care of the property, equipment, and spaces of CFJ and its community partners. Should a participant be reckless with their use of any of these spaces or materials that leads to damage, or could lead to damage, CFJ holds the right to give the participant an official warning.
Repeated Violations of Program Ground Rules: At the beginning of each program, staff will go over the ground rules and community agreements for the week. During this time, participants have the opportunity to add any ground rules or agreements that they would like the community to uphold during the program. Any repeated or blatant disregard or violations of these ground rules and agreements may result in an official warning and/or dismissal from the program.

Immediate Dismissal Policy: Some misdemeanors will result in the immediate dismissal from the program. Situations, behaviors, and actions resulting in immediate dismissal include:

Drugs and Alcohol: Should any participant be found in possession of drugs, alcohol, tobacco, any vaping products, and/or drug paraphernalia, CFJ holds the right to immediately dismiss them from the program. Should a program staff suspect that a participant is in possession of any of these items, CFJ holds the right to have the participants search their belongings in the presence of the program and/or CFJ staff.
Inappropriate touching (of sexual, violent, or bullying nature): CFJ has a zero tolerance policy for inappropriate physical contact.

Refund Policy for Dismissal: Participants who are asked to leave the program due to misdemeanors will not be issued a refund. The participant's family is responsible for any expenses to cover property damages and/or transportation as a result of the dismissal.

By registering my child,

to participate

in,

program. I am confirming that my child and I have read and agree to the Disciplinary and Dismissal Policy outlined above from CFJ.

Please select the program that you are registering for:

Please select which school or parish you are participating with:

Please select all the years that your child has participated in the JusticeworX program (including 2023).

20192020202120222023

Program Week:

Payment Information

Are you a recipient of a JusticeWorx Scholarship?

YesNo

Program Cost

Would you like to cover the 2.5% credit card processing fee?

YesNo

Total Cost

Program Cost

Would you like to cover the 2.5% credit card processing fee?

YesNo

Total Cost

Program Cost

Would you like to cover the 2.5% credit card processing fee?

YesNo

Total Cost

Program Cost

Would you like to cover the 2.5% credit card processing fee?

YesNo

Total Cost

Credit Card Information

First Name

Last Name

Credit Card Number

Security Code

Total Cost

Billing Address same as Youth Home Address?

YesNo

Billing Street

Billing City

State

Zip Code

Registration Information

The next page will have a review of all the information entered. Please review and ensure all information is entered correctly.

The registration will not be completed until you review and press submit on the next page

Contact Information