JPAC Registration Form

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Thank you for your interest in joining YouthFirst in Sacramento to lobby for mental health and social media bills. Your time and energy are so appreciated! We will leave on Monday morning, May 11, for Sacramento and spend the night at the Hyatt. Monday's lobbying efforts will be with just the YouthFirst teens and staff on the bill we’ve selected and worked on, and then we will join other California Jewish participants on Monday evening for the JPAC dinner and program. On May 12, we will join separate lobbying groups to learn about additional bills, then return with those groups to the Capitol to lobby for the new bill on Tuesday afternoon. We will return to the Bay Area on Tuesday evening.

The cost of the trip is highly subsidized by JFCS and includes transportation to and from Sacramento, the hotel, conference, and meals.

We ask for a participant fee of $72 for PMHA participants and $118 for all other JFCS teens. Cancellation Policy: Full refund until March 31, otherwise, no refund for cancellations after March 31.

Payment will be collected at the end of this form. We cannot guarantee the teen's participation until payment has been received. Financial Aid is available; contact Deb Massey at Dmassey@jfcs.org with any questions about financial aid before completing this form.

Are you a PMHA Participant?

YesNo

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Parent / Guardian 1 Fields

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Cell Phone

Parent/Guardian Email Address

Parent / Guardian 2 Fields

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Cell Phone

Parent/Guardian Email Address

Teen Waiver for JFCS Program:I, the undersigned, am the parent or the legal guardian of the applicant named above. I am aware that my above-named child is applying to participate in a YouthFirst program at JFCS. Permission is hereby given to Jewish Family and Children’s Services to accept him/her to work and volunteer with JFCS clients, and it is my responsibility to contact the Program Coordinator if at any time during the assignment this permission is revoked.

I hereby authorize my above-named child to participate, including related travel and other activities. Specifically, I authorize my teen to be driven to and from the Bay Area to Sacramento for this event. My child has permission to engage in all program activities except as otherwise specified in writing by me. Should the need arise for medical attention or treatment, including hospitalization and/or surgery, during the child’s participation in the above-described activity, I hereby grant permission for my child to be treated by qualified medical or emergency personnel at the discretion of Jewish Family and Children’s Services, with the cost paid solely by me.

I hereby agree and consent to the use of the photograph(s) hereinafter described for publicity purposes (including but not limited to news releases, newsletters, brochures, reports, advertising, reproduction in print, video, electronic/web forms and exhibits), forever, and I waive all claims for any compensation for such use and/or damages. Additionally, I consent to the use of any/all video footage at JFCS development and marketing meetings/events, and I waive all claims for any compensation for such use and/or damages.

Please sign your name below:

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Mailing address is same as billing address

Billing Address

Billing Street

Billing City

Billing State/Province

Billing Postal Code

Billing Address (Copied from Mailing Address)

Verify the address information below is correct. If not, go back to your mailing address and correct the information. You may also uncheck "Mailing address is same as billing address" and manually re-enter your billing address.

Billing Street

Billing City

Billing State

Billing Postal Code

Credit Card Information

First Name

Last Name

Card Number

Code

Billing Email

TOTAL

Authnet_Hidden_Fields

Registration Summary

After you click submit, please wait for the confirmation page to load. It may take several seconds. Clicking submit more than once could result in multiple submissions. If your payment is not confirmed within a few minutes, please contact billinginquiries@jfcs.org and include "YouthFirst-JPAC Billing Inquiry" in the subject. You should also receive a confirmation email.